Inspection Reports for
Brookhaven Nursing &Amp; Rehab
3405 WEST MT VERNON, SPRINGFIELD, MO, 65802-5241
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
13.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
144% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
78% occupied
Based on a September 2025 inspection.
Occupancy rate 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
Life Safety
Census: 75
Capacity: 90
Deficiencies: 4
Date: Dec 13, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations, focusing on HVAC and electrical equipment safety.
Findings
The facility failed to ensure proper installation and maintenance of HVAC ventilation fans and fire dampers, and failed to maintain electrical equipment by allowing improper use of power taps, extension cords, and outlet extenders. These deficiencies posed potential fire and electrical hazards affecting residents, staff, and visitors.
Deficiencies (4)
K521 HVAC: The facility failed to ensure two vents on two smoke sections had fire dampers or were vented outside, risking fire spread through attic space. This noncompliance affects all residents, staff, and visitors.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility allowed improper use of power taps, extension cords, and outlet extenders in patient care areas, risking fire or electrical injury. Multiple rooms had power strips and extension cords improperly used or overloaded.
A1102 Ventilation Requirements: The ventilation requirements per Table I were not met, linked to the K521 HVAC deficiency.
A3037 Extension Cords/Duplex Receptacles: Extension cords were used improperly, not UL-approved, or placed where subject to damage, linked to K920 electrical deficiencies.
Report Facts
Facility capacity: 90
Census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Responsible for compliance with ventilation fans and power tap usage; interviewed during inspection | |
| Administrator | Responsible for compliance with ventilation fans and power tap usage; interviewed during inspection |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 6
Date: Oct 13, 2023
Visit Reason
The inspection was conducted in response to allegations of verbal and emotional abuse by a Certified Nurse Aide towards a resident, as well as failure to report and investigate the abuse allegations properly.
Complaint Details
The complaint investigation was substantiated as the facility failed to protect the resident from verbal and emotional abuse and failed to report and investigate the abuse allegations properly. The facility census was 70 at the time of the survey.
Findings
The facility failed to protect a resident from verbal and emotional abuse by a staff member and did not report allegations of abuse within the required timeframe. The facility also failed to conduct a thorough investigation of the abuse allegations and did not document reporting to the State Survey Agency as required.
Deficiencies (6)
F600: The facility failed to protect the resident from verbal and emotional abuse by a Certified Nurse Aide who yelled at and belittled the resident.
F609: The facility failed to report allegations of abuse within two hours to the State Survey Agency and other officials as required by policy and law.
F610: The facility failed to thoroughly investigate allegations of resident abuse and did not document completion of a full investigation.
A4074: The facility failed to provide twenty-four hour protective oversight and supervision for residents on voluntary leave.
A8023: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents and requiring reporting to the department.
A8025: The facility failed to immediately report suspected abuse or neglect to the department and Department of Mental Health as required.
Report Facts
Facility census: 70
Deficiency counts: 6
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
Annual Inspection
Census: 69
Deficiencies: 2
Date: Aug 24, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations regarding resident care and notification of changes in condition.
Findings
The facility failed to notify a resident's representative in a timely manner after the resident sustained a fall with injury. Documentation and notification procedures related to the fall and subsequent medical evaluations were not properly followed.
Deficiencies (2)
F580 Notification of Changes. The facility failed to notify one resident's representative in a timely manner after the resident sustained a fall with injury, and did not document notification of the fall, family representative, or x-ray results.
A4088 Notify Responsible Party-Change in Condition. The facility did not immediately notify the person designated as the responsible party in the resident's record after a significant change in condition, as referenced in F580.
Report Facts
Facility census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Interviewed regarding post-fall assessment and notification procedures | |
| Licensed Practical Nurse (LPN) B | Interviewed regarding post-fall procedures and notifications | |
| Assistant Director of Nursing (ADON) | Interviewed regarding notification timelines and procedures after resident falls |
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
Plan of Correction
Census: 68
Deficiencies: 8
Date: Jun 8, 2023
Visit Reason
The document is a Plan of Correction submitted by Brookhaven Nursing & Rehab following a survey conducted from 06/05/2023 to 06/08/2023. It addresses deficiencies cited in the facility's recent inspection.
Findings
The Plan of Correction responds to multiple deficiencies including resident dignity issues, infection control, medication errors, food safety, and notification requirements. The facility outlines corrective actions and timelines to address these issues.
Deficiencies (8)
F-550 Resident Rights: The facility failed to ensure residents' dignity was protected when staff did not assist a resident who disrobed in common areas and failed to update the care plan accordingly.
F-582 Medicaid/Medicare Coverage: The facility failed to provide required notices to Medicaid-eligible residents regarding coverage and charges, including Skilled Nursing Facility Advance Beneficiary Notices.
F-623 Notice Requirements Before Transfer/Discharge: The facility failed to notify residents and their representatives in writing about transfers or discharges to hospitals for three sampled residents.
F-690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to provide incontinent care that prevented infection for one resident and failed to follow proper hand hygiene and catheter care practices.
F-760 Residents are Free of Significant Medication Errors: The facility failed to ensure all residents were free of significant medication errors, including late administration and improper priming of insulin pens.
F-812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to ensure food was stored, prepared, and served in a sanitary manner, including cleaning and maintenance of the ice machine and proper food labeling.
F-880 Infection Prevention & Control: The facility failed to maintain an effective infection prevention program, including hand hygiene, cleaning of glucometers, and use of personal protective equipment.
F-921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to provide a sanitary environment in the kitchen, including cleaning of the ice machine vents and refrigerator fans.
Report Facts
Facility census: 68
Plan of Correction completion date: Jul 23, 2023
Inspection Report
Life Safety
Census: 68
Capacity: 90
Deficiencies: 8
Date: Jun 8, 2023
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations at Brookhaven Nursing & Rehab.
Findings
The facility failed to maintain the integrity of building construction for fire safety, including unsealed penetrations affecting smoke barriers and sprinkler systems, improper delayed-egress locking arrangements, inadequate sprinkler head maintenance, failure to conduct required fire drills, and lack of policies for maintenance of fire safety systems. These deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (8)
K161: The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations allowing smoke passage, affecting multiple resident areas.
K222: The facility failed to ensure two egress doors with delayed-egress locking released properly after 15 seconds, preventing emergency egress.
K353: The facility failed to ensure sprinkler heads were free from debris, with obstructed sprinkler heads found in the attic.
K372: The facility failed to maintain smoke barrier walls and ceilings, with multiple unsealed penetrations found in smoke barriers.
K712: The facility failed to conduct fire drills at varied times including all shifts, missing documentation for some drills in the fourth quarter of 2022.
K741: The facility failed to maintain the grounds of the smoking area free from cigarette butts and lacked a policy for smoking area maintenance.
K918: The facility failed to complete a required four-hour load test of the emergency generator within the past three years and lacked a policy for generator testing.
K920: The facility failed to maintain the electrical system by allowing improper use of power taps and extension cords, risking fire or electrical injury.
Report Facts
Facility capacity: 90
Resident census: 68
Delayed-egress locking doors: 15
Fire drills required: 12
Fire drills conducted: 3
Generator inspection frequency: 12
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 4, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Complaint Details
This was a complaint investigation related to COVID-19 preparedness and infection control. No deficiencies were found or cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Census: 66
Deficiencies: 2
Date: Jan 11, 2022
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on compliance with COVID-19 screening and infection control policies.
Findings
The facility failed to maintain an effective infection control program as one staff member with COVID-19 symptoms was allowed to work. The screening process was inadequate, and rapid COVID-19 tests were not properly administered or interpreted.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to maintain an effective infection control program as a staff member with COVID-19 symptoms was allowed to work and screening forms were inaccurately completed.
A4086 Infection Control/Communicable Disease: The facility did not meet infection control regulations as evidenced by failure to report a communicable disease within seven days.
Report Facts
Facility census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook M | Staff member who worked while symptomatic and was involved in COVID-19 screening issues | |
| Licensed Practical Nurse Q | LPN | Staff member screened and cleared to work despite COVID-19 symptoms |
| RN B | Registered Nurse | Present during rapid COVID-19 testing and involved in testing process |
| DON | Director of Nursing | Interviewed regarding screening and testing procedures |
| Administrator | Provided interviews about screening and testing procedures |
Inspection Report
Re-Inspection
Census: 69
Deficiencies: 4
Date: Dec 29, 2021
Visit Reason
The inspection was conducted to investigate a deficiency related to accident hazards and supervision, specifically concerning a resident who accessed hand sanitizer without proper supervision.
Findings
The facility failed to keep one resident safe by allowing unsupervised access to hand sanitizer, which posed an accident hazard. Multiple interviews and observations confirmed that the medical supply closet was not properly secured and residents could access hazardous items.
Deficiencies (4)
F689 Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2). The facility failed to keep one resident safe by allowing unsupervised access to hand sanitizer from a locked medical supply closet, posing an accident hazard.
A4074 19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave. The facility did not ensure 24-hour protective oversight and supervision for residents on voluntary leave as required.
F557 Respect, Dignity/Right to have Personal Property CFR(s): 483.10(e)(2). The facility failed to ensure residents were treated with dignity and respect, as evidenced by staff yelling and calling residents names.
A8030 19 CSR 30-88.010(29) Dignity/Privacy. The facility failed to treat residents with consideration, respect, and dignity, including privacy in treatment and care.
Report Facts
Facility census: 69
Academy census: 22
Facility census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Certified Medication Technician (CMT) | Named in dignity and respect deficiency for yelling and calling residents names |
| Certified Medication Technician CMT A | Certified Medication Technician | Named in multiple findings related to resident interactions and behavior |
Inspection Report
Plan of Correction
Census: 70
Deficiencies: 2
Date: Oct 22, 2021
Visit Reason
The inspection was conducted to investigate and document deficiencies related to misappropriation and exploitation of resident property, specifically concerning medication management and security.
Findings
The facility failed to protect residents from misappropriation of medication, with one resident's pain medication unaccounted for. The facility lacked a policy regarding misappropriation of resident property and had discrepancies in medication counts and documentation.
Deficiencies (2)
F602: The resident's right to be free from misappropriation was not met as staff could not account for one resident's pain medication. The facility census was 70 and no policy was provided regarding misappropriation of resident property.
A4054: The facility failed to maintain a safe and effective medication system as evidenced by the findings in F602 regarding medication misappropriation.
Report Facts
Facility census: 70
Medication tablets documented lost: 30
Medication tablets per card: 30
Medication tablets total: 60
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 4
Date: Sep 27, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure residents had reasonable access to a telephone and failure to notify responsible parties of significant changes in residents' conditions.
Complaint Details
The complaint investigation was substantiated based on findings that the facility restricted a resident's telephone access and failed to notify the guardian and physician timely about a significant change in condition and hospital transfer.
Findings
The facility failed to ensure all residents had reasonable access to a telephone, specifically limiting one resident's ability to make calls. The facility also failed to notify the resident's guardian and physician in a timely manner about a significant change in condition and hospital transfer.
Deficiencies (4)
F 576 Right to Forms of Communication with Privacy: The facility failed to ensure all residents had reasonable access to a telephone, limiting one resident's ability to call specific persons. Staff did not update the resident's care plan to reflect phone use restrictions.
F 580 Notify of Changes (Injury/Decline/Room, etc.): The facility failed to notify the resident's guardian in a timely manner about a significant change in condition and hospital transfer. No policy was provided regarding guardian/family notification.
A4087 Notify Responsible Party-Change in Condition: Facility staff did not immediately notify the designated responsible party of a significant change in the resident's condition as required.
A8032 Resident Communicate With Persons of Choice: Residents must be permitted to communicate privately with persons of their choice. The facility placed unreasonable limitations on telephone use for one resident.
Report Facts
Facility census: 67
Inspection Report
Abbreviated Survey
Census: 54
Deficiencies: 2
Date: Feb 23, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess compliance with dialysis-related care standards.
Findings
The facility failed to ensure proper communication and coordination with the dialysis center for a resident requiring dialysis, including lack of physician orders and transportation arrangements. Documentation and staff reporting regarding dialysis appointments and refusals were inadequate.
Deficiencies (2)
F698 Dialysis. The facility failed to ensure residents requiring dialysis received services consistent with professional standards, including communication, physician orders, and transportation for one resident.
A4074 Nursing Care per Resident Condition. The facility did not provide personal attention and nursing care consistent with residents' conditions and current nursing practice.
Report Facts
Facility census: 54
Missed dialysis appointments: 9
Dialysis attendance frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided dialysis center appointment printout and interviews regarding dialysis care | |
| Social Service Designee (SSD) | Interviewed regarding transportation and communication issues | |
| Licensed Practical Nurse (LPN) A | Interviewed about resident dialysis refusals and nursing documentation | |
| Licensed Practical Nurse (LPN) B | Interviewed about resident dialysis refusals and nursing documentation | |
| Administrator | Interviewed about transportation arrangements and resident refusals |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 20, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No state licensure deficiencies were cited as a result of this complaint only investigation. No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with all applicable COVID-19 emergency preparedness and infection control requirements. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 13, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with related regulations and CDC recommended practices.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
This was a complaint investigation related to COVID-19 focused infection control. No deficiencies were cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 1, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparedness.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and infection control. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess the facility's compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 25, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 (b)(6) and CMS and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Jun 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
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 |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 10
Date: Jan 31, 2020
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, and misappropriation of resident property, as well as to investigate medication errors and other quality of care concerns.
Complaint Details
The complaint investigation was substantiated with findings of failure to ensure resident privacy, incomplete investigations of alleged misappropriation, medication errors, and other quality of care issues.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident privacy, incomplete investigations of alleged misappropriation, failure to notify physicians of wounds, improper wound care, medication errors exceeding acceptable rates, improper storage of medications, inadequate staffing of qualified dietary personnel, and failure to maintain proper ventilation systems.
Deficiencies (10)
F583 Personal Privacy/Confidentiality of Records: The facility failed to ensure privacy for one resident, including failure to close doors and cover residents when exposed.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to complete a thorough investigation of alleged misappropriation of resident property for two residents.
F684 Quality of Care: The facility failed to notify the physician of a new wound and failed to apply treatment as ordered for one resident.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to obtain a physician order for continuous oxygen and failed to identify, develop, and implement interventions for oxygen use for one resident.
F700 Bedrails: The facility failed to complete side rail assessments, obtain consent, and ensure proper use for three residents.
F759 Free of Medication Error Rates 5 Percent or More: The facility failed to ensure staff administered medications with an error rate less than 5%, resulting in an error rate of 7.69%.
F760 Residents are Free of Significant Med Errors: The facility failed to ensure residents were free from significant medication errors related to insulin pen priming and administration for one resident.
F761 Label/Store Drugs and Biologicals: The facility failed to store temperature-sensitive medications at appropriate temperatures in two refrigerators.
F801 Qualified Dietary Staff: The facility failed to employ sufficient qualified dietary staff and ensure proper training and certification.
F923 Ventilation: The facility failed to maintain residents' bathroom exhaust ventilation systems in proper working condition.
Report Facts
Facility census: 75
Sample size: 20
Medication error rate: 7.69
Medication error threshold: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA K | Certified Nursing Assistant | Named in misappropriation allegation and investigation |
| Director of Nursing | Director of Nursing | Provided statements regarding privacy policy and investigation procedures |
| LPN D | Licensed Practical Nurse | Observed providing wound care and medication administration |
| LPN B | Licensed Practical Nurse | Interviewed regarding wound care treatments |
| LPN A | Licensed Practical Nurse | Interviewed regarding insulin administration and resident care |
| Registered Nurse P | Registered Nurse | Interviewed regarding resident oxygen use |
| MDS Coordinator | MDS Coordinator | Interviewed regarding resident care plans and oxygen therapy |
Inspection Report
Life Safety
Census: 75
Capacity: 90
Deficiencies: 2
Date: Jan 31, 2020
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association, specifically regarding egress doors and locking arrangements.
Findings
The facility failed to ensure that magnetically locked doors would unlock and sound upon activation of the fire alarm system. Several doors with magnetic locking devices did not unlock or sound during fire alarm tests, posing a potential safety risk to residents, staff, and visitors.
Deficiencies (2)
K222 Egress Doors: The facility failed to ensure magnetically locked doors unlocked and sounded upon fire alarm activation, as observed during fire alarm tests at multiple doors.
A2041 Door Locks: Door locks did not meet NFPA 101 requirements for being operable from the inside by simple devices or knobs, with only one lock permitted per door.
Report Facts
Facility census: 75
Total capacity: 90
Inspection Report
Plan of Correction
Census: 76
Deficiencies: 2
Date: Oct 30, 2019
Visit Reason
The inspection was conducted to investigate deficiencies related to resident rights and dignity at Brookhaven Nursing & Rehab, including allegations of disrespectful treatment by the Activity Director.
Findings
The facility failed to ensure all residents were treated with dignity and respect, as evidenced by multiple interviews and record reviews showing the Activity Director used disrespectful language toward residents. Several staff statements and resident interviews confirmed inappropriate behavior.
Deficiencies (2)
F550 Resident Rights/Exercise of Rights. The facility failed to treat residents with respect and dignity, demonstrated by the Activity Director's use of disrespectful language and behavior toward residents.
A8030 Dignity/Privacy. The facility did not meet the requirement to treat each resident with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and care.
Report Facts
Facility census: 76
Inspection Report
Plan of Correction
Census: 71
Deficiencies: 2
Date: Mar 13, 2019
Visit Reason
The document is a Plan of Correction submitted by Brookhaven Nursing & Rehab following a survey conducted on March 13, 2019, addressing deficiencies related to resident care and documentation.
Findings
The facility failed to ensure consistent documentation and accessibility of residents' code status, specifically regarding Do Not Resuscitate (DNR) orders, resulting in a resident receiving CPR despite a DNR status. The facility lacked a signed DNR form for Resident #1, and staff did not properly update or verify code status documentation.
Deficiencies (2)
F678 Cardio-Pulmonary Resuscitation (CPR) personnel failed to ensure one resident's code status was consistently documented and accessible, leading to CPR being performed despite a DNR status.
A4074 Nursing care per resident condition was not met as evidenced by failure to maintain accurate and consistent code status documentation for Resident #1.
Report Facts
Census: 71
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 19, 2019
Visit Reason
The inspection was conducted as a licensure inspection and complaint investigation for Brookhaven Nursing & Rehab.
Complaint Details
The complaint investigation found no deficiencies and no state licensure violations.
Findings
No health facility survey deficiencies were cited. No state licensure deficiencies were cited as a result of this inspection and complaint investigation.
Inspection Report
Life Safety
Census: 79
Capacity: 90
Deficiencies: 2
Date: Feb 19, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
Findings
The facility failed to maintain the integrity of the building construction by not maintaining the one-hour fire rating of the ceilings and having unsealed penetrations between the attic and areas below. These deficiencies had the potential to affect all residents, staff, and visitors by allowing smoke to pass between areas in the event of a fire.
Deficiencies (2)
K161: The facility failed to maintain the one-hour fire rating of the ceilings and had unsealed penetrations between the attic and areas below, allowing smoke to pass between these areas. Specific issues included missing escutcheons around sprinkler heads and ceiling tiles lifted or missing near various rooms and hallways.
A3001: The building was not substantially constructed and maintained in good repair as required by 19 CSR 30-85.032(2). This regulation was not met due to the deficiencies noted in K161.
Report Facts
Facility capacity: 90
Resident census: 79
Inspection Report
Life Safety
Census: 77
Capacity: 90
Deficiencies: 4
Date: Jan 18, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations, including sprinkler system installation, supervisory signals, smoking regulations, and electrical systems.
Findings
The facility failed to meet several Life Safety Code requirements including incomplete fire sprinkler coverage, lack of electronic supervisory monitoring for the sprinkler system, inadequate smoking signage, and incomplete documentation of weekly generator inspections. These deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (4)
K351: The facility failed to provide complete fire sprinkler coverage by omitting a sprinkler in the bathroom of resident room 110.
K352: The facility failed to provide an electronic supervisory monitoring device for the Post Indicator Valve that alerts if the water is shut off to the fire sprinkler system.
K741: The facility failed to properly label the building as a non-smoking facility and did not post no smoking signs where oxygen was in use.
K918: The facility failed to document complete weekly generator inspections, including checking drive belts and hoses, despite visual inspections being performed.
Report Facts
Facility capacity: 90
Resident census: 77
Document
Deficiencies: 0
Visit Reason
The document does not contain any readable inspection or regulatory information to determine the visit reason.
Findings
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