Brookhaven Nursing & Rehab
BROOKHAVEN NURSING & REHAB in SPRINGFIELD, MO — inspection on September 4, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
cart. He/she was not sure of exact words, but felt it was a threat. RN C was the charge nurse and
came out of a resident's room and a nurse aide was standing in the center at the ends of all the halls.
was close to the cart. By the time he/she had gotten close, it had settled down.
After the disagreement at med cart, he/she asked the resident to go back to his/her room, they would get his/her meds, but it would be just a bit.
The resident went outside to have a cigarette.
The resident said to RN C, that CMT F said he/she was going to make the resident his/her last one to received medications. RN C told the resident not to worry about it as he/she wouldn't allow that to happen as that wouldn't be appropriate. He/she thought that was the end and CNA A came to him/her and said that CMT F told the resident if you bump into my cart that will be the last time you bump my cart;-He/she messaged the DON;-RN C got the resident's meds and administered them.During an interview on 09/03/25, at 2:12 P.M., CNA D said threats would be disrespectful.
During an interview on 09/03/25, at 2:27 P.M., CNA E said he/she has seen CMT F be hateful to residents. If staff threaten a resident, it's disrespectful.
During an interview on 09/04/25, at 8:45 A.M., Licensed Practical Nurse (LPN) G said the following:-He/she has witnessed CMT F be disrespectful to residents;-Saying to a resident if they do something that will be the last time they do it would be disrespectful.During an interview on 09/03/25, at 3: 24 P.M., the DON said the following:-If staff suspect something against a resident's rights, they need to report that to the charge nurse and the DON;-Some residents have behaviors, but staff have received training on interventions;-If a resident is having a bad day, staff need to help them to feel better;-The resident does have triggers;-He/she was notified by CMT F about the incident with the resident and when on the phone with the CMT, the charge nurse also called;-RN C reported to the DON that CMT F said to the resident if you hit the med cart again it would be the last time you do that.
When the DON questioned CMT F what was meant by the statement, the CMT said he/she meant things could be done like notifying the nurse, calling the police or medication changes;-The statement like that should never be made to a resident and it is disrespectful.During an interview on 09/04/25, at 10:05 A.M., the Administrator said the following:-He/she expected staff to intervene if they see staff treating residents disrespectfully;-He/she expected staff to report any concerns related resident rights to the nurse and administration;-It is not acceptable to say to a resident if you touch me or my med cart, or hit me or my med cart, I'll be the last person you hit.Complaint #2604357
265835 09/04/2025
Brookhaven Nursing & Rehab 3405 West MT Vernon Springfield, MO 65802
some medications are always late.During interviews on 09/03/25, at 1:32 P.M., Registered Nurse (RN)
halls;-Medications may be administered one hour before and one hour after the prescribed time. If
medications as ordered by the physician.During interviews on 09/03/25 at 1:50 P.M., RN C said the following:-The facility has one CMT to administer medications on 100 through 300 halls and one back in the academy;-Medications can be administered one hour prior and one hour after the ordered time;-He/she knows there are timeliness issues;-Staff should be passing them within the time frames.
During an interview on 09/03/25, at 2:12 P.M., Certified Nurse Aide (CNA) D said he/she has received complaints from residents about medications not being passed timely, mainly in the afternoon.
During an interview on 09/03/25, at 2:27 P.M., CNA E said he/she has received complaints about residents not getting their medications timely.
During an interview on 09/03/25, at 2:36 P.M., CMT F said the following:-He/she knows which meds to pass by looking at the MAR;-He/she knows the staff have one hour before and one hour after the time to pass a medication;-He/she passed medications as ordered, except it's impossible to pass them on time as he/she was responsible for 58 residents.
During an interview on 09/03/25, at 3:24 P.M., the Director of Nursing (DON) said the following:-He/she has two CMTs that work the floor.
One is on the 400 and 500 halls and the other covers 100 through 300 halls.
The 100 to 300 halls have around 49 residents. It's the responsibility of the CMT to pass all the meds on their halls;-Medications can be passed one hour before and one hour after the ordered time;-If the medication is ordered at 8 A.M., and it's administered after 10:00 A.M., that would be considered late;-He/she expects staff to pass medications as ordered by the physician.
During an interview on 09/04/25, at 8:45 A.M., Licensed Practical Nurse (LPN) G said the following:-Staff know what medications and times to pass meds by looking at the MAR.
Medications may be passed one hour before and one hour after the ordered time;-If a medication is ordered at 8:00 A.M., it would need to be passed no later than 9:00 A.M.
Passing an 8:00 A.M., med after 10:00 A.M., would mean it's late and it would be a medication error;-Staff should be following the physician's orders.
During an interview on 09/04/25, at 10:05 A.M., the Administrator said the following:-He/she wasn't aware medications were being administered late, until yesterday;-If the medication is not administered timely, an hour before or an hour after the med time, by policy it could be a medication error;-He/she expected staff to pass medications as ordered.Complaint 2604358
265835 09/04/2025
Brookhaven Nursing & Rehab 3405 West MT Vernon Springfield, MO 65802
and he/she almost overdosed.
During an interview on 09/04/25, at 10:05 A.M., the Administrator said
triple check the system to ensure medications are entered and administered as ordered;-He/she
would expect staff to reach out to the provider, and document the information;-He/she expected staff to pass medications as ordered.Complaint 2584214
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.