Inspection Reports for
Brookhaven Nursing &Amp; Rehab
3405 WEST MT VERNON, SPRINGFIELD, MO, 65802-5241
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
70 residents
Based on a September 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 3
Date: Sep 4, 2025
Visit Reason
The inspection was conducted in response to complaints regarding resident rights violations, medication administration timeliness, and pharmaceutical service deficiencies at Brookhaven Nursing & Rehab.
Complaint Details
Complaint #2604357 involved resident rights violations with staff verbal threats. Complaint #2604358 involved late medication administration. Complaint #2584214 involved pharmaceutical service failures including medication transcription and administration errors after hospital discharge.
Findings
The facility failed to protect a resident's right to dignity and respect due to staff verbal threats, failed to administer medications timely to a resident, and failed to provide proper pharmaceutical services including accurate transcription and administration of medication orders for a resident discharged from the hospital.
Deficiencies (3)
Failed to protect resident's right to dignity and respect when staff spoke disrespectfully and threateningly to a resident.
Failed to provide timely administration of medications to a resident, with medications given over two hours late.
Failed to provide pharmaceutical services meeting resident needs, including failure to properly transcribe, clarify, and administer medications as ordered after hospital discharge.
Report Facts
Facility census: 70
Medication administration delay: 135
Residents affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician F | Certified Medication Technician | Named in resident rights violation involving verbal threats and disrespectful communication |
| Director of Nursing | Director of Nursing (DON) | Documented incident and interviewed regarding resident rights violation and medication administration |
| Certified Nurse Aide H | Certified Nurse Aide (CNA) | Provided statement regarding verbal threats by staff |
| Housekeeper Supervisor | Housekeeper Supervisor (HS) | Overheard verbal altercation between resident and staff |
| Certified Medication Technician A | Certified Medication Technician (CMT) | Observed administering medications late and interviewed about medication administration processes |
| Registered Nurse B | Registered Nurse (RN) | Interviewed regarding medication administration and staff conduct |
| Registered Nurse C | Registered Nurse (RN) Charge Nurse | Involved in incident de-escalation and interviewed about staff conduct |
| Licensed Practical Nurse G | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and staff conduct |
| Nurse Practitioner | Nurse Practitioner (NP) | Interviewed regarding medication order discrepancies and pharmaceutical services |
| Administrator | Facility Administrator | Interviewed regarding expectations for staff conduct and medication administration |
Inspection Report
Routine
Census: 75
Capacity: 75
Deficiencies: 15
Date: Dec 13, 2024
Visit Reason
Routine inspection of Brookhaven Nursing & Rehab to assess compliance with healthcare regulations including resident care, medication administration, infection control, and facility safety.
Findings
The facility had multiple deficiencies including failure to complete required PASARR screening for one resident, inconsistent documentation of code status for another resident, inadequate wound care documentation and treatment, unsafe smoking practices, medication administration errors including unavailable medications and improper insulin timing, poor food temperature and quality, improper dish drying practices, and lapses in infection control including incomplete TB screening for staff, improper catheter care, medication contamination risks, inadequate hand hygiene, and failure to properly sanitize wound care supplies and glucometers.
Deficiencies (15)
Failed to complete required PASARR screening for one resident prior to admission.
Failed to ensure consistent code status documentation for one resident.
Failed to follow physician orders and document wound care assessments and treatments for one resident with an elbow wound.
Failed to document regular wound assessments for one resident with a pressure ulcer to the right hip.
Failed to complete smoking assessment and care plan for one resident and allowed residents to keep smoking supplies on their person and in their rooms contrary to policy.
Failed to have ordered medications on hand for administration for two residents, resulting in multiple doses not administered due to unavailability.
Failed to provide a meal or snack within appropriate time after administration of rapid acting insulin for one resident.
Failed to ensure food served was palatable and at safe temperatures; multiple residents reported cold or bland food; observed food temperatures below recommended levels.
Failed to allow dishes to air dry before stacking, resulting in visible water droplets trapped and potential bacterial growth.
Failed to complete two-step TB skin test screening for three staff members per policy and standards of practice.
Failed to maintain catheter bag and tubing off the floor for one resident, risking contamination.
Failed to prevent contamination of medications by staff touching medication cups and pills with bare hands during medication administration to five residents.
Failed to perform proper hand hygiene during incontinent care for one resident, risking cross-contamination.
Failed to sanitize wound care supplies between residents and failed to perform hand hygiene during wound care for one resident.
Failed to properly clean and disinfect multi-resident use glucometer between uses for two residents.
Report Facts
Medication doses not administered: 18
Medication doses not administered: 13
Medication doses not administered: 9
Medication doses not administered: 21
Medication error rate: 12.5
Food temperature: 127
Food temperature: 129.7
Food temperature: 123.2
Food temperature: 58
Food temperature: 75
Food temperature: 97.1
Food temperature: 85.9
Food temperature: 54.2
Wound measurement: 3.5
Wound measurement: 2.5
Wound measurement: 2.3
Wound measurement: 3.1
Wound measurement: 0.2
Wound measurement: 0.3
Wound measurement: 1.2
Wound measurement: 3
Wound measurement: 1.5
Wound measurement: 1.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA N | Certified Nurse Aide | Failed to complete two-step TB skin test |
| LPN D | Licensed Practical Nurse | Failed to complete two-step TB skin test; observed medication and wound care deficiencies |
| DA M | Dietary Aide | Failed to complete two-step TB skin test |
| CMT B | Certified Medication Technician | Observed medication administration errors and improper hand hygiene |
| CMT C | Certified Medication Technician | Interviewed about medication administration and insulin timing |
| LPN E | Licensed Practical Nurse | Interviewed about medication administration, hand hygiene, and wound care |
| CNA H | Certified Nurse Aide | Interviewed about incontinent care and smoking supplies |
| LPN F | Licensed Practical Nurse | Observed performing wound care with lapses in hand hygiene and sanitization |
| LPN G | Licensed Practical Nurse | Observed performing wound care with lapses in hand hygiene and sanitization |
| Dietary Manager | Interviewed about food quality and dish drying practices | |
| Administrator | Interviewed about policy adherence for medication administration, smoking, food service, and infection control | |
| Director of Nursing | Interviewed about medication administration, smoking, hand hygiene, and infection control | |
| Assistant Director of Nursing | Interviewed about medication administration, smoking, hand hygiene, and infection control |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 3
Date: Oct 13, 2023
Visit Reason
The inspection was conducted due to allegations of verbal and emotional abuse by a staff member towards a resident (Resident #1). The investigation focused on the facility's failure to protect the resident from abuse and to timely report and investigate the allegations.
Complaint Details
The complaint involved allegations of verbal and emotional abuse by CNA B towards Resident #1. Multiple staff interviews and written statements confirmed inappropriate and provocative behavior by CNA B. The facility failed to report the abuse allegations to the State Survey Agency within the required two-hour timeframe and did not document an investigation. The Administrator was not informed of the abuse allegations by staff or the resident.
Findings
The facility failed to protect Resident #1 from verbal and emotional abuse by a Certified Nurse Aide (CNA B), who yelled at and belittled the resident. Staff statements confirmed inappropriate behavior by CNA B. The facility also failed to timely report the abuse allegations to the State Survey Agency within two hours and did not conduct a full investigation or document the investigation of the abuse allegations.
Deficiencies (3)
Failed to protect Resident #1 from verbal and emotional abuse by a staff member.
Failed to timely report allegations of abuse to the State Survey Agency within two hours.
Failed to document completion of a full investigation of the abuse allegation.
Report Facts
Facility census: 70
Resident admission date: Dec 16, 2022
MDS assessment date: Sep 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nurse Aide | Named in verbal and emotional abuse findings towards Resident #1 |
| LPN A | Licensed Practical Nurse | Witnessed abuse incident and provided statements |
| CNA F | Certified Nurse Aide | Witnessed abuse incident and provided statements |
| CNA G | Certified Nurse Aide | Witnessed abuse incident and provided statements |
| LPN E | Licensed Practical Nurse | Provided statements regarding abuse incident and reporting |
| CMT C | Certified Medication Tech | Provided statements regarding abuse incident and reporting |
| Administrator | Administrator | Not informed of abuse allegations by staff or resident |
| Assistant Director of Nursing | Assistant Director of Nursing | Not informed of abuse allegations by staff or resident |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
Date: Aug 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's representative in a timely manner following a change in the resident's condition, including falls.
Complaint Details
The complaint investigation found that the facility did not notify the resident's representative after a fall on 07/28/23, despite physician orders for x-rays and no documented notification of the family or representative of the fall, orders, or x-ray results.
Findings
The facility staff failed to notify one resident's representative promptly after the resident sustained a fall and had a change in condition. Documentation and notification procedures were not followed as required, including failure to notify the resident's family of the fall, physician orders, and x-ray results.
Deficiencies (1)
Facility staff failed to notify one resident's representative in a timely manner when the resident had a change in condition, including falls.
Report Facts
Facility census: 69
Date of resident fall: Jul 28, 2023
Inspection Report
Routine
Census: 68
Deficiencies: 3
Date: Jun 8, 2023
Visit Reason
The inspection was conducted to assess compliance with resident rights, infection control, catheter care, and medication administration standards at Brookhaven Nursing & Rehab.
Findings
The facility failed to ensure resident dignity related to disrobing behavior, failed to provide proper incontinent and catheter care with appropriate hand hygiene, and failed to follow infection prevention protocols during medication administration and glucometer use.
Deficiencies (3)
Failed to ensure resident dignity when staff did not timely assist a resident who disrobed in common areas and failed to update care plan accordingly.
Failed to provide incontinent care and catheter care per standards, including failure to perform proper hand hygiene.
Failed to use appropriate infection control procedures including hand hygiene during incontinent care, glucometer use, and medication pass.
Report Facts
Facility census: 68
Resident admission date: Sep 1, 2016
Resident admission date: May 11, 2023
Resident admission date: Apr 28, 2016
Resident admission date: Mar 17, 2023
Deficiency counts: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant D | CNA | Mentioned in relation to resident disrobing behavior and dignity issue |
| Certified Medication Technician E | CMT | Mentioned in relation to resident disrobing behavior and dignity issue |
| Registered Nurse C | RN | Mentioned in relation to resident disrobing behavior and infection control expectations |
| Assistant Director of Nursing | ADON | Mentioned in relation to resident disrobing behavior and infection control expectations |
| Director of Nursing | DON/MDS Coordinator | Mentioned in relation to resident disrobing behavior and infection control expectations |
| Certified Nurse Aide G | CNA | Observed failing to perform hand hygiene during catheter care |
| Certified Nurse Aide F | CNA | Mentioned regarding hand hygiene expectations |
| Licensed Practical Nurse H | LPN | Observed failing hand hygiene during glucometer use and medication administration |
| Administrator | Provided statements on expectations for resident dignity and infection control |
Inspection Report
Routine
Census: 68
Deficiencies: 8
Date: Jun 8, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident dignity, notification of Medicare coverage changes, transfer/discharge notifications, incontinent care, medication administration, infection control, food safety, and facility cleanliness.
Findings
The facility was found deficient in multiple areas including failure to protect resident dignity related to disrobing behavior, failure to provide required Medicare notices, failure to notify residents and representatives of hospital transfers in writing, inadequate incontinent and catheter care, medication administration errors including late medication passes and improper insulin pen use, failure to maintain infection control practices including hand hygiene and glucometer cleaning, improper food storage and handling including expired foods and unclean ice machine, and failure to maintain sanitary conditions in the kitchen including unclean refrigerator fan and ice machine vents.
Deficiencies (8)
Failure to ensure resident dignity when staff failed to timely assist a resident who disrobed in common areas and failed to update care plan with new interventions.
Failure to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) at initiation, reduction, or termination of Medicare Part A benefits for three residents.
Failure to provide timely written notification to resident and representative before transfer or discharge to hospital for three residents.
Failure to provide appropriate incontinent care and catheter care per standards, including failure to perform hand hygiene and proper catheter cleaning.
Failure to ensure residents were free from significant medication errors including late medication administration and improper insulin pen use.
Failure to ensure food was stored, prepared, and distributed to prevent contamination including unclean ice machine, expired refrigerated foods, and wet dishes stored on trays.
Failure to implement infection prevention and control program including inadequate hand hygiene during incontinent care, glucometer use, and medication pass.
Failure to maintain sanitary environment including unclean vents on ice machine and unclean fan in walk-in refrigerator.
Report Facts
Facility census: 68
Residents affected by dignity deficiency: 1
Residents affected by Medicare notice deficiency: 3
Residents affected by transfer notification deficiency: 3
Residents affected by incontinent care deficiency: 1
Residents affected by medication errors: 3
Residents affected by infection control deficiency: 2
Residents affected by food safety deficiency: 68
Residents affected by sanitary environment deficiency: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN H | Licensed Practical Nurse | Named in medication administration errors and infection control deficiencies |
| CNA D | Certified Nursing Assistant | Named in dignity and infection control deficiencies |
| CNA F | Certified Nursing Assistant | Named in infection control deficiencies |
| CNA G | Certified Nursing Assistant | Named in incontinent care and infection control deficiencies |
| CMT E | Certified Medication Technician | Named in dignity and infection control deficiencies |
| RN C | Registered Nurse | Named in dignity and infection control deficiencies |
| ADON | Assistant Director of Nursing | Named in dignity, medication, and infection control deficiencies |
| DON | Director of Nursing | Named in dignity, medication, and infection control deficiencies |
| Administrator | Administrator | Named in dignity, Medicare notice, transfer notification, medication, food safety, and infection control deficiencies |
| Dietary Manager | Dietary Manager | Named in food safety and sanitary environment deficiencies |
| Dietary Aide A | Dietary Aide | Named in food safety and sanitary environment deficiencies |
| Dietary Aide B | Dietary Aide | Named in food safety and sanitary environment deficiencies |
| Maintenance Supervisor | Maintenance Supervisor | Named in sanitary environment deficiencies |
Inspection Report
Routine
Census: 75
Deficiencies: 10
Date: Jan 31, 2020
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident privacy, investigation of alleged violations, wound care, oxygen therapy, bed rail use, medication administration, medication storage, dietary staffing, and ventilation systems.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy, incomplete investigations of alleged misappropriation, failure to notify physicians and follow wound care orders, lack of physician orders and care plan interventions for oxygen use, failure to complete side rail assessments and obtain consent, medication administration errors including failure to prime insulin pens, inconsistent refrigerator temperature monitoring, employment of an unqualified dietary manager, and non-functioning bathroom exhaust ventilation systems.
Deficiencies (10)
Failed to ensure privacy for one resident by not closing doors or covering exposed residents during care.
Failed to complete investigation of alleged misappropriation of resident property for two residents.
Failed to notify physician of new wound, obtain physician's order for wound care, and failed to use proper hand hygiene during wound care.
Failed to obtain physician order and develop care plan interventions for continuous oxygen use for one resident.
Failed to complete side rail assessment, risk/benefit review, and obtain informed consent for side rails for three residents.
Failed to administer insulin correctly by not priming the insulin pen before injection for one resident.
Failed to ensure medication error rates were less than 5%, with two errors out of 26 opportunities.
Failed to ensure temperature-sensitive medications were stored at appropriate temperatures; refrigerator temperatures were often not documented and were out of range without follow-up.
Failed to employ a qualified dietary manager with accredited education in food service management.
Failed to maintain functioning bathroom exhaust ventilation systems in 16 residents' bathrooms.
Report Facts
Census: 75
Medication errors: 2
Refrigerator temperature log missing days: 21
Refrigerator temperature log missing days: 7
Insulin dose: 24
Insulin dose: 8
Oxygen flow rate: 2
Number of residents with non-functioning bathroom exhaust: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Administered insulin without priming pen; described insulin administration practices |
| LPN B | Licensed Practical Nurse | Described wound care and insulin administration practices; noted refrigerator temperature documentation issues |
| Director of Nursing | Director of Nursing (DON) | Provided information on privacy policy, wound care, oxygen protocol, insulin administration, refrigerator temperature monitoring, and side rail assessment process |
| Certified Nursing Assistant M | Certified Nurse Assistant | Described resident privacy practices |
| Certified Nursing Assistant L | Certified Nurse Assistant | Described resident oxygen use |
| Restorative Assistant Q | Restorative Nursing Assistant | Described resident privacy practices |
| Licensed Practical Nurse D | Licensed Practical Nurse | Observed performing wound care without proper hand hygiene and without physician orders |
| Certified Medication Technician F | Certified Medication Technician | Described refrigerator temperature monitoring practices |
| Dietary Manager | Dietary Manager | Reported lack of certification and experience in food service management |
| Maintenance Supervisor | Maintenance Supervisor | Unaware of non-functioning bathroom exhaust ventilation systems |
| MDS Coordinator | Minimum Data Set Coordinator | New to role; behind on care plans and side rail assessments |
| Administrator | Facility Administrator | Described investigation process and side rail assessment process |
| Director of Rehabilitation | Director of Rehabilitation | Described screening process for side rails |
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