Brookestone View

bed-hold policies.

record review and interview, the facility failed to notify a resident's responsible party of bed hold at

failed to notify the ombudsman in writing of a resident's transfer from the facility as required for 1 (Resident 57) of 2 sampled residents.

The facility census was 53.

Findings are:A.

Record review of a facility supplied document titled Notice of Bed Hold Policy and not dated revealed when a resident requires hospitalization or therapeutic leave, the facility advises the resident and the family of the bed hold policy in writing. In the case of an emergency transfer the notice is provided to the family within 24 hours of the transfer.

Record review of Resident 1's Progress Notes revealed documentation on 12/29/2025 at 2:11 PM that Resident 1 was transferred out of the facility to the local emergency room and a copy of the facility's bed hold policy was sent with the resident. On 12/30/2026 the Social Service Director (SSD) documented that they mailed the bed hold to the resident's family/responsible party for them to return and sign the document.

Record Review of a facility supplied document titled Resident Transfer Record -V2 dated 12/29/2025 revealed documentation that the bed hold policy was given to the resident.

There was no documentation present reflecting the resident's family/responsible party was notified of the bed hold at the time of the resident's transfer. In an interview completed on 06/02/2024 at 3:15 PM with the facility Social Service Director (SSD), the SSD stated that the facility process is to give the Notice of Bed Hold Policy document to the resident at the time of the transfer and the SSD on the next business day following the transfer will mail the Notice of Bed Hold Policy document to the residents responsible party.

The SSD confirmed that there was no documentation present in Resident 1's Electronic Health Record (EHR) indicating that the resident's responsible party/family was notified of the Notice of Bed Hold Policy for Resident 1's admission to the hospital on [DATE]. In an interview completed on 06/03/2026 at 2:00 PM with the Regional Administrator (RA), the RA confirmed that there was no documentation prior to the SSD documentation that the Notice of Bed Hold Policy was mailed to the resident's responsible party/family indicating that they were notified at the time of the transfer of the resident's bed hold.

B.

Record review of Resident 57's Progress Notes revealed on 03/23/2026 at 5:37 PM the facility was notified that Resident 57 was being admitted to the hospital. On 03/27/2026 the resident's family members came to the facility and picked up the resident's belongings to be taken to the resident's new care facility.

Record review of a facility supplied document titled Action Summary and dated 04/06/2026 with a date range listed as 03/01/2026 to 03/31/2026 revealed no listing of Resident 57's transfer from the facility and admission to the hospital. In an interview completed on 06/02/2026 at 3:15 PM with the facility SSD, the SSD confirmed that the document titled Action Summary was the document that was sent once a month to the ombudsman and served as the notification to the ombudsman of the residents that had transferred out of the facility during the the designated date range.

The SSD confirmed that Resident 57 was admitted to the hospital and then discharged from the facility due to being admitted to another care facility from the hospital.

The SSD confirmed that the resident's transfer or discharge from the facility was not listed on the report supplied to the ombudsman and should have been.

285297 06/04/2026

Brookestone View 850 Laurel Parkway Drive Broken Bow, NE 68822

catheter care, and appropriate care to prevent urinary tract infections.

Reference Number 175 NAC 12-006.09(H)(iv) Based on record review, observation, and interview the

and infection for 1 (Resident 48) of 1 sampled resident.

The facility census was 53.

Findings are:A record review of Resident 48's undated Care Plan revealed the resident was admitted to the facility on [DATE], had a foley catheter (a tube that is inserted into the bladder to aide in draining urine), and was at risk for infection due to the history of Urinary Tract Infection.

The Care Plan also contained an intervention for the staff to provide catheter care every shift with proper technique. In an observation completed on 06/03/2026 from 7:35 AM to 7:56 AM of catheter cares being provided to Resident 48 by Nurse Aide B (NA-B) the following was observed:-NA-B placed a package of disposable wipes, an incontinence product, and a box of disposable gloves on the foot of Resident 48's bed without first placing a clean barrier on the bed. -Resident 48 had been incontinent of a bowel movement. NA-B obtained a wipe from the disposable wipe container and used it to begin cleansing the resident's skin.

NA-B used the same soiled, gloved hand to obtain additional wipes from the container and finished cleansing the BM from the resident's skin. -Without first changing gloves and without the benefit of hand hygiene, NA-B then grasped the resident's catheter with their gloved hand and used a disposable wipe to cleanse the tubing. NA-B repeated this action twice with the same disposable wipe. -NA-B then concluded assisting the resident with their needs. In an interview completed with NA-B on 06/03/2026 at 1:30 PM, NA-B confirmed that they were trained to use the disposable wipes for catheter care.

The NA confirmed that they placed the supplies (package of disposable wipes, brief, and box of gloves) directly on the foot of Resident 48's bed and did not place a clean barrier between the items and the resident's bed.

The NA confirmed that they did not change their gloves after cleansing the resident's visible soiling and prior to obtaining new, clean disposable wipes from the package.

The NA confirmed that they were unsure if it was acceptable to use the same area of the disposable wipe when wiping down the catheter tubing. In an interview completed on 06/03/2026 at 2:50 PM with the facility Infection Control Nurse (ICP), the ICP confirmed that the NA should have provided a clean barrier between the supplies and the resident's bed and did not, and confirmed that the NA should have removed their gloves and completed hand hygiene after cleansing the resident's visible soiling and obtaining new clean disposable wipes.

The ICP confirmed that a separate area of the disposable cloth or a new cloth should have been used for each wipe down the catheter.