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BROOKHAVEN NURSING & REHAB Inspection Report, Violations & Safety Grade (SPRINGFIELD, Missouri)

3405 WEST MT VERNON, SPRINGFIELD, Missouri 65802

Phone: 4178749600

CMS Overall:3/5

Overview & Bed Count

Certified Beds
90
Avg Residents/Day
62.7
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Greene
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall3/5
Health3/5
Staffing3/5
Quality3/5

Nurse Staffing Check

MetricThis FacilityMissouri AvgDifference
RN Hours per Resident per Day0.490.46+0.03
Total Nurse Hours per Resident per Day3.483.40+0.08
CMS Staffing Rating3/52.2/5-
Nursing Staff Turnover68.2%56.9%-

Health Citation History

36 health citations on record

DateCategoryDescriptionSeverity
2026-04-24Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2025-09-04Resident Rights DeficienciesHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D – Moderate Harm Potential
2025-09-04Resident Assessment and Care Planning DeficienciesEnsure services provided by the nursing facility meet professional standards of quality.D – Moderate Harm Potential
2025-09-04Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.D – Moderate Harm Potential
2024-12-13Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.E – Moderate Harm Potential
2024-12-13Nutrition and Dietary DeficienciesEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.E – Moderate Harm Potential
2024-12-13Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2024-12-13Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential
2024-12-13Resident Assessment and Care Planning DeficienciesPASARR screening for Mental disorders or Intellectual DisabilitiesD – Moderate Harm Potential
2024-12-13Quality of Life and Care DeficienciesProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.D – Moderate Harm Potential
2024-12-13Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2024-12-13Quality of Life and Care DeficienciesProvide appropriate pressure ulcer care and prevent new ulcers from developing.D – Moderate Harm Potential
2024-12-13Pharmacy Service DeficienciesProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.D – Moderate Harm Potential
2024-12-13Pharmacy Service DeficienciesEnsure medication error rates are not 5 percent or greater.D – Moderate Harm Potential
2024-12-13Pharmacy Service DeficienciesEnsure that residents are free from significant medication errors.D – Moderate Harm Potential
2023-10-13Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D – Moderate Harm Potential
2023-10-13Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D – Moderate Harm Potential
2023-10-13Freedom from Abuse, Neglect, and Exploitation DeficienciesRespond appropriately to all alleged violations.D – Moderate Harm Potential
2023-06-08Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2023-06-08Resident Rights DeficienciesGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.E – Moderate Harm Potential
2023-06-08Resident Rights DeficienciesProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.E – Moderate Harm Potential
2023-06-08Pharmacy Service DeficienciesEnsure that residents are free from significant medication errors.E – Moderate Harm Potential
2023-06-08Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential
2023-06-08Environmental DeficienciesMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.E – Moderate Harm Potential
2023-06-08Resident Rights DeficienciesHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D – Moderate Harm Potential
2023-06-08Quality of Life and Care DeficienciesProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.D – Moderate Harm Potential
2020-01-31Quality of Life and Care DeficienciesTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.E – Moderate Harm Potential
2020-01-31Environmental DeficienciesHave enough outside ventilation via a window or mechanical ventilation, or both.E – Moderate Harm Potential
2020-01-31Resident Rights DeficienciesKeep residents' personal and medical records private and confidential.D – Moderate Harm Potential
2020-01-31Freedom from Abuse, Neglect, and Exploitation DeficienciesRespond appropriately to all alleged violations.D – Moderate Harm Potential
2020-01-31Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2020-01-31Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2020-01-31Pharmacy Service DeficienciesEnsure medication error rates are not 5 percent or greater.D – Moderate Harm Potential
2020-01-31Pharmacy Service DeficienciesEnsure that residents are free from significant medication errors.D – Moderate Harm Potential
2020-01-31Pharmacy Service DeficienciesEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.D – Moderate Harm Potential
2020-01-31Nutrition and Dietary DeficienciesEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.D – Moderate Harm Potential

Fire Safety Citation History

11 fire safety citations on record

DateCategoryDescriptionSeverity
2024-12-13Services DeficienciesEnsure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.F – Moderate Harm Potential
2024-12-13Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.F – Moderate Harm Potential
2023-06-08Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2023-06-08Miscellaneous DeficienciesHave simulated fire drills held at unexpected times.F – Moderate Harm Potential
2023-06-08Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.F – Moderate Harm Potential
2023-06-08Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.F – Moderate Harm Potential
2023-06-08Construction DeficienciesUse approved construction type or materials.E – Moderate Harm Potential
2023-06-08Egress DeficienciesAdd doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.E – Moderate Harm Potential
2023-06-08Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.E – Moderate Harm Potential
2023-06-08Miscellaneous DeficienciesHave posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.E – Moderate Harm Potential
2020-01-31Egress DeficienciesAdd doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.E – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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