Brooken Hill Health & Rehab: Care Order Failures - AR
The incident at Brooken Hill Health and Rehab occurred on October 27, 2025, when LPN #6 decided to remove staples from Resident #2's surgical wound after noticing post-operative orders indicated they should have been removed the day before.
"Most of the time we don't get orders on admission to remove them, but I don't mind taking them out if the surgeon is ok with it," the LPN told inspectors during a November 7 interview.
The resident had been admitted on Saturday, October 25. When the LPN arrived Monday morning, he found orders stating staples should be removed on post-operative day 10 — which had been Sunday. He observed no drainage and only light serosanguinous drainage on the dressing that was dry. The wound appeared pink with no open areas.
"I removed them first thing in the morning and about 3-4 hours later I got called that the wound dehisced," the LPN said. "It was about 2-2.5 inches long at the top and deep enough you could put fingers in there."
Nobody else had examined the wound before he removed the staples.
The patient reportedly had a coughing fit and felt her dressing leak shortly after the staple removal. An operative note from October 28 documented the devastating result: dehiscence of the postoperative abdominal wound with colon protruding through the midline incision.
Surgeons had to debride the fascial edges and close the wound again, placing an onlay vicryl mesh for temporary support.
The LPN acknowledged he had no wound nurse certification. His wound-specific education came from "hands on work over the last couple of years." He described knowing to look for signs of dehiscence and erythema, and to assess for new epithelial tissue that was pink and purple.
But he failed to consult with qualified medical staff before proceeding with the staple removal.
The facility's Advanced Practice Registered Nurse told inspectors she typically would not see surgical incisions unless the surgeon had released the wound to the nursing home's care. She explained that saturated dressings might indicate an underlying pocket rather than infection, and that separated edges warranted surgeon notification.
"They could have called me as a resource, I am always available, but I would have referred them to the surgeon," the APRN said.
The Director of Nursing couldn't identify who completed the resident's admission that Saturday. She said wound care should start with following orders and documenting in the Electronic Health Record, with the treatment nurse tracking all wounds in the building.
The Administrator stated that on weekends, the nurse on duty would do assessments and the treatment nurse would follow up when they returned.
The Medical Director told inspectors he would expect an RN to have more knowledge than an LPN for such procedures. He didn't recall staff contacting him that Saturday — it would have been an on-call provider. He assumed someone like the Assistant Director of Nursing would ensure surgical wounds were properly managed for weekend admissions.
The inspection revealed a breakdown in communication and oversight that allowed an unqualified nurse to make a critical decision about surgical wound care without proper consultation. The resident required emergency surgery to repair damage that could have been prevented with appropriate medical supervision.
Federal inspectors cited the facility for failing to provide the necessary care and services to attain the highest practicable physical well-being for residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brooken Hill Health and Rehab, LLC from 2025-11-07 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 20, 2026 · Our methodology
BROOKEN HILL HEALTH AND REHAB, LLC in FORT SMITH, AR was cited for violations during a health inspection on November 7, 2025.
The resident had been admitted on Saturday, October 25.
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.