Brookhaven Nursing & Rehab

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

nurses' station, from another resident's room. He/she heard CMT F say this lady is kicking my med cart, I need you to come up here;- He/she went to the cart and CMT F was near the cart, but the resident was not close to the cart. He/she asked the resident to go to his/her room and he/she told CMT F he/she needed to be professional and could not fight with residents;-CMT F got louder and said you don't understand, he/she's kicking my med cart. RN B said we have to watch our presentation. We can all get overwhelmed;-As he/she walked away, CMT F kept saying if he/she kicks my med cart one time, and I didn't hear exactly what CMT F said, but CNA H was there and heard it. He/she thought CMT F said something like, that would be the last time he/she kicked my cart. He/she was not sure of exact words, but felt it was a threat. RN C was the charge nurse and he/she reported it to the DON;-Threats are disrespectful.During an interview on 09/03/25, at 1:50 P.M., RN C said the following:-CMT F began his/her medication pass, going down 300 hall. He/she came out of a resident's room and a nurse aide was standing in the center at the ends of all the halls. The CNA H said hey, we need you something going on.;-CMT F was at his/her cart and the resident 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

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brookhaven Nursing & Rehab

3405 West MT Vernon Springfield, MO 65802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

MARs tell staff which medications and times the medications are to be administered;-Staff clicks each medication in the electronic record and that indicated staff administered the medication;-Medications can be administered one hour before or after the time they're due, if it's given after that time frame it's late;-There is one CMT for halls 100, 200, and 300, which is around 50 residents. He/she has the heaviest medication load in the morning and some medications are always late.During interviews on 09/03/25, at 1:32 P.M., Registered Nurse (RN) B said the following:-The MARS shows staff what medications to administer and the time to administer:-The facility has one CMT for halls 100 through 300, and one CMT on 400 and 500 halls;-Medications may be administered one hour before and one hour after the prescribed time. If staff administer an 8:00 A.M., after 9:00 A.M., it would be given late;-Staff should be administering 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

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brookhaven Nursing & Rehab

3405 West MT Vernon Springfield, MO 65802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

nurse did not put in the correct medications, the nurse put in several medications the resident isn't taking;-He/she told the nurse to put the resident back on the medications the resident was taking when he/she went to the hospital;-He/she didn't get the paperwork from the hospital until 08/07/25;-He/she knew

the hospital had the resident taking the fluphenazine, but the resident hadn't been on this medication since February;-He/she didn't know if the facility sent the resident with any paperwork showing the medications

the resident has been taking at the facility, but he/she should have been sent with current orders;-The resident was discharged from the hospital on [DATE REDACTED]. He/she saw the resident at the facility on 08/05/25.

The facility had no documentation from the hospital on which meds the resident was to be taking;-The medication list in the EHR on 08/05/25 did not match anything;-He/she expected staff to give medications as ordered and if they have questions, they need to reach out to the providers;-The nurse that admitted the resident placed orders for medications that should not have been done;-It took until 08/07/25 to get the medications straightened out, and the resident had already gone back to the hospital;-He/she doesn't change psychiatric meds because he/she is not a psychiatrist and expects an MD or psych doctor to make

the necessary changes;-If staff don't pass medication as prescribed it's a medication error;-A similar incident happened back in February or March when the staff doubled all the resident's medications and he/she almost overdosed.During an interview on 09/04/25, at 10:05 A.M., the Administrator said the following:-The charge nurse that's admitting a resident from the hospital is in charge of verifying the medication orders with the attending physician. Typically, there would be a system to double, or triple check

the system to ensure medications are entered and administered as ordered;-He/she would expect staff to add medications as ordered from the hospital. If there are questions, 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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