Brookhaven Nursing & Rehab: Medication Errors - MO
The failure at Brookhaven Nursing & Rehab came to light during a complaint inspection completed September 4, 2025. According to the inspection report, the resident was discharged from the hospital and returned to Brookhaven on August 5. The facility had no documentation from the hospital that day specifying which medications the resident should be taking. The medication list in the electronic health record on August 5 did not, in the words of one person interviewed, "match anything."
The nurse who admitted the resident placed orders for medications the resident was not taking. Among them was fluphenazine, an antipsychotic the resident had not been on since February. The admitting nurse also entered several other medications the resident wasn't taking, while apparently omitting the ones the resident had actually been on before the hospitalization.
Nobody caught it for two days.
The facility didn't receive paperwork from the hospital until August 7. By then, the resident had already gone back.
A provider interviewed during the inspection described the situation with notable frustration. The nurse had put in several medications the resident wasn't taking, the provider said, and had not put the resident back on the medications the resident was taking before the hospital stay. The provider said he or she didn't know whether the facility had sent the resident to the hospital with any paperwork showing current medication orders, but acknowledged the resident should have gone with current orders. When the provider saw the resident at the facility on August 5, the medication list in the electronic health record didn't correspond to anything the provider recognized as accurate.
The provider also said he or she does not change psychiatric medications independently, expecting instead that an MD or psychiatrist make those calls. Entering a psychiatric medication that a resident had been off for six months, without any such direction, was not something the provider had authorized.
What made the inspector's findings harder to dismiss was what the provider said next. A similar incident had happened back in February or March. During that earlier episode, staff had doubled all of the resident's medications. The resident nearly overdosed.
That prior incident did not appear to have produced the kind of systemic fix that would have prevented what happened in August.
The administrator, interviewed the morning of the inspection, described what the process was supposed to look like. The charge nurse admitting a resident from the hospital is responsible for verifying medication orders with the attending physician. There would typically be a system to double or triple check that medications were entered and administered as ordered. Staff were expected to pass medications as ordered, and if they had questions, they were expected to reach out to the provider and document the conversation.
That system did not work on August 5.
The inspection cited the facility under F0755, which covers pharmacy services and medication management, at a harm level described as minimal harm or potential for actual harm, affecting few residents. The citation reflects the regulatory floor, not necessarily the ceiling of what occurred. A resident who received incorrect psychiatric medications for two days, who had nearly overdosed on doubled medications months earlier at the same facility, and who ended up rehospitalized before anyone corrected the orders, is a resident whose situation inspectors classified as potential harm.
The provider's description of the August 7 resolution was matter-of-fact: it took until that date to get the medications straightened out. The resident, by then, was already gone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookhaven Nursing & Rehab from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 30, 2026 · Our methodology
BROOKHAVEN NURSING & REHAB in SPRINGFIELD, MO was cited for violations during a health inspection on September 4, 2025.
The failure at Brookhaven Nursing & Rehab came to light during a complaint inspection completed September 4, 2025.
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.