Brookestone View: Catheter Care Failures Risked Infection - NE
Inspectors watched the whole thing happen.
A June 2026 federal inspection of Brookestone View, a 53-bed nursing facility in Broken Bow, Nebraska, documented a catheter care procedure so flawed that the facility's own infection control nurse confirmed nearly every step of it was wrong. The inspection focused on one resident, identified in records as Resident 48, who had a foley catheter and a documented history of urinary tract infections. The resident's care plan specifically called for catheter care every shift using proper technique.
What inspectors observed on the morning of June 3, beginning at 7:35 a.m., was something different.
The aide, identified in the report as Nurse Aide B, started by placing supplies directly on the foot of the resident's bed: a package of disposable wipes, an incontinence product, a box of gloves. No clean barrier went down first. The supplies sat on the same surface where a resident with an infection history would sleep.
Resident 48 had been incontinent of a bowel movement. The aide pulled a wipe from the container and began cleaning the resident's skin. Then, with the same soiled glove still on, the aide reached back into the wipe container to pull out more. The contaminated glove touched the clean wipes.
The aide never changed gloves.
Without any glove change and without washing hands, the aide then reached for the resident's catheter tubing and wiped it down. The same disposable wipe was used to clean the tubing twice more. A catheter is a direct line into the bladder. For a resident already flagged as infection-prone, the tubing is exactly where contamination cannot go.
When inspectors interviewed Nurse Aide B that afternoon, the aide confirmed each detail. The supplies had gone directly on the bed with no barrier underneath. The gloves had not been changed between cleaning the bowel movement and reaching into the clean wipe package. And when it came to the catheter itself, the aide said they were unsure whether it was acceptable to use the same area of a wipe when cleaning the tubing.
The facility's infection control nurse, interviewed the same day, confirmed that every one of those steps was a failure. A clean barrier should have been placed on the bed before any supplies were set down. The gloves should have come off, and hands should have been washed, before the aide touched the clean wipe package. And a separate area of the cloth, or a new cloth entirely, should have been used for each pass over the catheter tubing.
The inspection report rated the violation as causing minimal harm or potential for actual harm. Resident 48's outcome is not described in the report.
What the report does describe is a trained aide who knew the wipes were meant for catheter care, confirmed the steps they took, and still could not say with certainty whether reusing the same soiled wipe surface on a catheter was acceptable. That uncertainty, in a resident with a documented infection history and a tube running into their bladder, is the condition Brookestone View's infection control protocols were supposed to prevent.
The care plan said proper technique, every shift. On the morning inspectors watched, that is not what Resident 48 received.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookestone View from 2026-06-04 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Brookestone View in Broken Bow, NE was cited for violations during a health inspection on June 4, 2026.
Inspectors watched the whole thing happen.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.