Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 View during CMS and state inspections, most recent first.
A resident who required extensive help with personal hygiene had repeated findings of food debris in the wheelchair frame, seat, and armrest, along with eggs, crumbs, and other food in the lap crease of the shirt. The resident’s care plan directed staff to keep the environment clean, and the facility’s wheelchair cleaning schedule showed missing or inconsistent documentation for the resident’s wheelchair cleaning, despite the DON stating wheelchairs were expected to be cleaned weekly and as needed when visibly soiled.
The facility failed to notify a resident’s responsible party of the bed hold when the resident was transferred out, and failed to include another resident’s transfer/discharge on the monthly ombudsman report. Record review and staff interview showed the bed hold notice was given to the resident and mailed later to the family, but there was no documentation that the responsible party was notified at the time of transfer. The monthly Action Summary sent to the ombudsman also omitted a resident who was hospitalized and later discharged to another care facility.
Improper catheter care and infection control practices were observed for a resident with a Foley catheter and a history of UTI. A nurse aide placed supplies directly on the bed without a clean barrier, used the same gloved hand to handle clean wipes after cleansing stool, and then cleaned the catheter tubing without changing gloves or performing hand hygiene. The ICP confirmed the aide did not use proper technique.
The facility failed to ensure proper infection control and resident care, with staff not wearing masks correctly, inadequate hand hygiene, and improper cleaning of a resident's CPAP mask. A resident with severe cognitive impairment did not receive appropriate incontinence care, and PPE was not removed correctly, risking contamination.
A resident with severe cognitive impairment and mobility issues was not provided with a proper toileting plan, leading to prolonged periods without toileting and inadequate incontinence care. Observations showed the resident sitting in a wet wheelchair, and the nurse aide failed to perform proper hygiene or clean the wheelchair cushion. Facility staff confirmed the need for a toileting plan, acknowledging the deficiency.
A resident at risk for skin breakdown developed a deep tissue injury on the left heel due to the facility's failure to consistently implement prescribed interventions, such as using Prevlon boots and elevating feet. Observations showed lapses in care, including improper positioning and lack of routine skin checks. Communication breakdowns among staff further contributed to inadequate management of the pressure ulcer.
A resident, previously on hospice, was not provided with necessary restorative services after being removed from hospice care due to improvement. Despite requests from the resident's representative and the resident's ability to participate in exercises, the facility failed to update the care plan or provide therapy, citing staffing issues and communication breakdowns.
A facility failed to obtain a physician's order for CPAP settings and ensure a filter was present in a resident's CPAP machine. The resident, with COPD and Obstructive Sleep Apnea, was observed multiple times without a filter. The DON confirmed the absence of a filter and the need for specific CPAP settings according to physician orders.
The facility failed to ensure proper hand hygiene and gloving during wound care for a resident, did not handle contaminated laundry properly, and did not clean a resident's nebulizer kit after each treatment. These deficiencies were confirmed through observations and staff interviews.
The facility failed to follow physician's orders for administering Amlodipine and providing adequate fluid intake for a resident. The medication was given outside the specified blood pressure and pulse parameters, and the resident did not consistently receive the prescribed 8 ounces of fluid four times a day.
The facility failed to follow a prescribed oxygen order for a resident with multiple medical conditions, including pneumonia and heart failure. Observations revealed the resident's oxygen was not consistently set to the prescribed 2 l/m, and the facility lacked an oxygen policy to ensure proper administration.
Soiled wheelchair and clothing not kept clean
Penalty
Summary
The facility failed to ensure the resident environment was free of soiling and debris and cleaned consistently with facility practices for one resident who required extensive assistance with personal hygiene. The resident’s care plan directed staff to keep the environment clean and to ensure an environment conducive to comfort. During observations, the resident’s wheelchair was found to have food in between the wheelchair frame, seat, and armrest, and the resident also had eggs, crumbs, and other food items sitting in the lap crease of the shirt. The wheelchair remained soiled across multiple observations, including repeated findings of food in the wheelchair frame and armrest area even after the resident’s shirt had been cleaned. An interview with a nurse aide revealed that wheelchair cleaning was part of night shift duties and that the facility used a Nightshift binder with a wheelchair cleaning schedule. Record review of the cleaning schedule showed multiple missing forms for several date ranges and inconsistent documentation for the resident’s wheelchair cleaning, with some entries blank, some marked with a line through them, and some initialed. The DON stated the facility expected all resident wheelchairs to be cleaned weekly and as needed when visibly soiled, and later stated the resident’s wheelchair had been deep cleaned and daily checks had been initiated.
Failure to Notify Responsible Party of Bed Hold and Report Resident Transfer to Ombudsman
Penalty
Summary
The facility failed to notify a resident’s responsible party of the bed hold policy at the time the resident was transferred from the facility for an emergency room transfer. Record review showed the resident was sent out with a copy of the bed hold policy, and later documentation indicated the policy was mailed to the resident’s family/responsible party on the next business day. However, there was no documentation in the resident’s record showing that the family or responsible party was notified of the bed hold when the transfer occurred. The Social Service Director confirmed that the facility’s process was to give the notice to the resident at transfer and mail it to the responsible party afterward, and the Regional Administrator confirmed there was no documentation showing the responsible party was notified at the time of transfer. The facility also failed to include a resident’s transfer or discharge on the monthly report sent to the ombudsman. Record review showed the resident was admitted to the hospital and later discharged from the facility after being admitted to another care facility from the hospital. The facility’s monthly Action Summary, which the Social Service Director identified as the report sent to the ombudsman, did not list this resident’s transfer or discharge during the reporting period. The Social Service Director confirmed the resident should have been included on the report but was not.
Improper Catheter Care and Infection Control Practices
Penalty
Summary
Catheter care was not performed in a manner to prevent cross contamination and infection for a resident with a Foley catheter and a history of urinary tract infection. The resident’s care plan directed staff to provide catheter care every shift using proper technique. During observation, a nurse aide placed disposable wipes, an incontinence product, and gloves on the foot of the resident’s bed without first placing a clean barrier on the bed. The resident was incontinent of a bowel movement, and the nurse aide used a wipe to begin cleansing the resident’s skin. The aide then used the same soiled, gloved hand to obtain additional wipes from the container and finished cleansing the visible stool. Without changing gloves or performing hand hygiene, the aide grasped the resident’s catheter with the gloved hand and used a disposable wipe to cleanse the tubing, repeating the action twice with the same wipe. The nurse aide later confirmed the supplies had been placed directly on the bed, that gloves were not changed after cleansing the resident’s soiling, and that they were unsure whether it was acceptable to use the same area of the disposable wipe on the catheter tubing. The infection control nurse confirmed that a clean barrier should have been used, gloves should have been removed with hand hygiene performed after cleansing the visible soiling, and a separate area of the disposable cloth or a new cloth should have been used for each wipe down of the catheter.
Infection Control and Resident Care Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed by staff, which had the potential to affect all residents. Observations revealed that staff members, including Guest Relations staff, were not wearing masks correctly, with masks positioned below the nose. This was despite the facility's signage indicating that masks were required and the existing Covid-19 education guidelines that mandated masks to be worn over the nose and mouth. Additionally, laundry staff did not perform hand hygiene for the required 20 seconds after handling potentially contaminated items, as confirmed by both the staff member and the Housekeeping/Laundry Supervisor. Resident 109's CPAP mask was not cleaned daily as required, with observations noting facial oils and debris on the mask over several days. The resident, who was cognitively intact, confirmed that the facility did not clean the mask. The Director of Nursing acknowledged that the CPAP masks should be cleaned every day, as per the physician's orders and facility policy. Furthermore, laundry from a Covid-positive resident was placed on a counter without a barrier, risking contamination, and the staff member involved was unsure of the correct procedure. In another incident, Resident 11, who had severe cognitive impairment and was dependent on staff for toileting, did not receive appropriate incontinence care. The nurse aide failed to cleanse the resident properly after incontinence, did not perform hand hygiene, and did not change gloves during the process. The resident was left sitting on a wet wheelchair cushion, and the nurse aide improperly removed PPE, risking contamination. The Director of Nursing confirmed that the expected procedures for incontinence care and PPE removal were not followed.
Failure to Provide Adequate Toileting Interventions
Penalty
Summary
The facility failed to provide appropriate toileting interventions for a resident with severe cognitive impairment, dementia, and impaired mobility. The resident was readmitted to the facility with diagnoses including unspecified dementia, polyosteoarthritis, Parkinson's Disease, and muscle weakness. Despite the resident's severe cognitive impairment and dependency for toileting, the facility did not have a toileting plan in place as indicated by the resident's care plan and bladder assessment form. Observations revealed that the resident was left sitting in a wheelchair for extended periods without being toileted, resulting in the resident being found with soaked sweatpants and a wet wheelchair cushion. The nurse aide assisting the resident failed to provide proper incontinence care, did not perform hand hygiene, and did not clean the wheelchair cushion before seating the resident back in it. The documentation showed that the resident was only toileted at specific times, which was confirmed to be insufficient by the MDS nurse. Interviews with the Director of Nursing and the MDS nurse confirmed that the resident should have had a toileting plan due to their incontinence and mobility issues. The lack of a toileting schedule and inadequate incontinence care were acknowledged as deficiencies by the facility staff, highlighting a failure to adhere to the facility's bowel and bladder management policy.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to implement necessary interventions to prevent a pressure ulcer for Resident 20, who was identified as being at risk for skin breakdown. Despite having a Braden score indicating risk, the resident developed a deep tissue injury on the left heel. The resident was admitted with multiple health conditions, including Type 2 Diabetes Mellitus, chronic kidney disease, and muscle weakness, which contributed to their vulnerability to pressure ulcers. The initial care plan included pressure-relieving devices and regular repositioning, but these measures were not consistently followed. Observations and interviews revealed several lapses in care. Resident 20 was often found without the prescribed Prevlon boots or proper heel elevation, both of which are critical for off-loading pressure from the heels. The resident was observed sitting in a recliner with feet on the floor and in a wheelchair without feet elevated, contrary to the care plan. Additionally, the facility's policy on skin and wound management was not adhered to, as evidenced by the lack of routine skin checks and inconsistent documentation of the pressure ulcer record. Communication breakdowns among staff further contributed to the deficiency. The Dietary Manager was not informed of the resident's wound in a timely manner, delaying nutritional assessments that could support wound healing. The Wound Nurse and Therapy Manager were also not adequately informed about the resident's condition, preventing them from providing necessary interventions. These failures in communication and adherence to care protocols led to the development and inadequate management of the pressure ulcer, highlighting significant gaps in the facility's care processes.
Failure to Provide Restorative Services Post-Hospice
Penalty
Summary
The facility failed to provide necessary therapy or restorative services to a resident, identified as Resident 38, to prevent the decline of their condition. Resident 38 was admitted with diagnoses including weakness, Parkinsonism, and chronic pain, and was initially on hospice care but was removed due to improvement. Despite the removal from hospice, the resident's care plan continued to reflect a terminal prognosis, and no new care plan was developed to address the resident's current needs. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependency in activities of daily living, yet there was no care plan for therapy or restorative services. Interviews with the resident's representative and facility staff revealed a lack of communication and process for residents coming off hospice care. The resident's representative requested restorative services, but the facility failed to provide them, citing staffing issues. Observations showed that the resident was capable of participating in exercises and expressed feeling better when moving. The Social Service Director acknowledged the communication breakdown and the absence of a care plan meeting following the resident's significant change in status.
Failure to Ensure CPAP Machine Settings and Filter
Penalty
Summary
The facility failed to obtain a physician's order for the settings of a CPAP machine and ensure the machine had a filter for a resident. The resident, who was admitted to the facility with diagnoses of Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea, was observed multiple times without a filter in their CPAP machine. The resident's admission record and physician orders indicated the use of CPAP per home settings during sleep hours, but the specific settings were not verified with a physician's order. Observations conducted on different occasions confirmed the absence of a filter in the CPAP machine. An interview with the Director of Nursing corroborated the lack of a filter and the need for specific CPAP settings according to physician orders. The resident was cognitively intact, as indicated by a BIMS score of 14. The facility's failure to ensure the CPAP machine was equipped with a filter and to verify the practitioner's order for CPAP settings constituted a deficiency in providing safe and appropriate respiratory care.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene and gloving during wound care for Resident 29. The Licensed Practical Nurse (LPN) did not wear gloves on both hands while performing wound treatment and did not perform hand hygiene before donning a glove on the left hand. This was confirmed by the LPN during an interview. Additionally, the care plan for Resident 29 did not include a focus area or interventions for the coccyx wound, despite the resident having multiple medical diagnoses including Systemic Lupus Erythematosus, hypertension, and chronic skin integrity issues. The facility also failed to handle contaminated laundry properly. Observations revealed that staff members transported soiled linens without placing them in bags and did not perform hand hygiene after handling the soiled items. This was observed with multiple staff members, including a Medication Aide and a Nursing Assistant, who were seen carrying unbagged soiled linens and not performing hand hygiene afterward. The Director of Nursing confirmed that the expectation was for all soiled linens to be bagged for transport. Additionally, the facility did not ensure that Resident 21's nebulizer kit was cleaned after each treatment. Observations over several days showed that the nebulizer mask had a coating of facial oils and residual medication, indicating it had not been cleaned. The Licensed Practical Nurse confirmed that the nebulizer kit and mask should have been cleaned after each treatment but were not. Resident 21 had a history of traumatic brain injury and was moderately cognitively impaired, requiring substantial assistance with daily activities.
Failure to Follow Medication and Fluid Intake Orders
Penalty
Summary
The facility failed to ensure that the parameters for administering Amlodipine, a blood pressure medication, were followed for Resident 17. Despite the physician's order to hold the medication if the systolic blood pressure was less than 110, diastolic blood pressure was less than 50, or pulse was less than 60, the medication was administered outside these parameters on multiple occasions. Specifically, Amlodipine was given on dates when the resident's blood pressure and pulse readings were below the specified thresholds. Interviews with the Licensed Practical Nurse (LPN) and Medication Aide (MA) confirmed that the medication was administered incorrectly, and the Director of Nursing (DON) acknowledged that the medication should not have been given under those conditions. Additionally, the facility did not comply with the physician's order to provide Resident 17 with 8 ounces of fluid four times a day. The Medical Administration Records (MAR) for January, February, and March 2024 showed that the resident did not consistently receive the prescribed amount of fluids. The DON confirmed that the resident's fluid intake did not meet the ordered parameters. Interviews with the LPN further corroborated that the resident did not receive the required fluid intake as specified by the physician's order.
Failure to Follow Prescribed Oxygen Order
Penalty
Summary
The facility failed to ensure a valid oxygen order was followed for a resident. Resident 30, who had multiple medical diagnoses including unspecified bacterial pneumonia, obstructive sleep apnea, acute combined systolic and diastolic heart failure, cerebral infarction, and unspecified dementia, was admitted to the facility with a physician's order for continuous oxygen at 2 liters per minute (l/m) to maintain oxygen saturation above 90%. However, observations revealed that the resident's oxygen was not consistently set to the prescribed level. On one occasion, the oxygen flowmeter was set to 0 while the resident was seated in the dining room, and on another occasion, the flowmeter was set to 1 l/m instead of the prescribed 2 l/m. The resident confirmed the need for continuous oxygen at 2 l/m, and the Director of Nursing (DON) acknowledged the discrepancy and adjusted the flowmeter but did not set it to the correct level as per the discharge instructions from the hospital. Additionally, the facility lacked an oxygen policy, procedure, or guideline to ensure proper administration of oxygen therapy. The deficiency was further highlighted during an interview with the facility's Administrator, who confirmed the absence of an oxygen policy. The DON also confirmed that the resident should have been on continuous oxygen at 2 l/m as per the hospital discharge instructions. The failure to follow the prescribed oxygen order and the lack of a formal oxygen policy contributed to the deficiency in providing safe and appropriate respiratory care for Resident 30.
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What surveyors actually found near you
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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
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Nursing homes near Broken Bow
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Callaway Good Life Center, Inc | 16.8 mi | ★★★★★ | 15 | 0 |
| Rose Lane Home | 35.9 mi | — | 0 | 0 |
| Community Memorial Health Center | 36.9 mi | ★★★★★ | 10 | 0 |
| Arbor Care Centers - Ord, Llc | 38.7 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.