Springfield, MO

Brookhaven Nursing & Rehab

3-star overall rating with 3-star inspections with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

3405 West Mt Vernon, Springfield, MO

(417) 874-9600

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

James & Judy Lincoln

Operator or chain grouping

Approved since

2010-04-21

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.23

Registered nurse staffing

LPN hours / resident day

0.40

Licensed practical nurse staffing

Aide hours / resident day

2.47

Nurse aide staffing

Weekend hours

2.68

Weekend nurse staffing

RN turnover

Annual RN turnover

Total nurse turnover

42%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	75.9%	84.8% 8.9 pts worse	93.4% 17.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.8%	90.9% 7.9 pts better	95.5% 3.3 pts better	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	1.7%	4.1% 2.4 pts better	3.3% 1.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	4.9%	14.7% 9.8 pts better	11.4% 6.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	4.9%	5.5% 0.6 pts better	5.4% 0.5 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	42.2%	25.3% 16.9 pts worse	19.6% 22.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	42.3%	25.0% 17.3 pts worse	16.7% 25.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	9.2%	20.3% 11.1 pts better	16.3% 7.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	11.5%	19.8% 8.3 pts better	14.9% 3.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.5%	1.4% 0.1 pts worse	1.0% 0.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	7.3%	2.6% 4.7 pts worse	1.7% 5.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	12.4%	18.1% 5.7 pts better	19.8% 7.4 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	1.8%	5.0% 3.2 pts better	5.1% 3.3 pts better	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	82.8%	66.4% 16.4 pts better	81.7% 1.1 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who newly received an antipsychotic medication	2.6%	2.2% 0.4 pts worse	1.6% 1 pts worse	Short Stay · 2024Q4-2025Q3

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-13 · Fire 2024-12-13

14 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 2 Health 2023-06-08 · Fire 2023-06-08

8 health deficiencies

Top issue: Resident Rights (3 deficiencies)

8 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2020-01-31 · Fire 2020-01-31

14 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-13

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-01-27

F · Potential for more than minimal harm 2024-12-13

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-01-27

F · Potential for more than minimal harm 2023-06-08

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-07-23

F · Potential for more than minimal harm 2023-06-08

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-07-23

F · Potential for more than minimal harm 2023-06-08

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-07-23

F · Potential for more than minimal harm 2023-06-08

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-07-23

E · Potential for more than minimal harm 2023-06-08

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2023-07-23

E · Potential for more than minimal harm 2023-06-08

K222 · Egress Deficiencies

Fire Safety

Add 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.

Corrected 2023-07-23

E · Potential for more than minimal harm 2023-06-08

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-07-23

E · Potential for more than minimal harm 2023-06-08

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2023-07-23

E · Potential for more than minimal harm 2020-01-31

K222 · Egress Deficiencies

Fire Safety

Add 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.

Corrected 2020-03-15

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-04

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-10-19

D · Potential for more than minimal harm 2025-09-04

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-10-19

D · Potential for more than minimal harm 2025-09-04

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-10-19

E · Potential for more than minimal harm 2024-12-13

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-01-27

E · Potential for more than minimal harm 2024-12-13

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-01-27

E · Potential for more than minimal harm 2024-12-13

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-01-27

E · Potential for more than minimal harm 2024-12-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-10

D · Potential for more than minimal harm 2024-12-13

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2025-01-27

D · Potential for more than minimal harm 2024-12-13

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2025-01-27

D · Potential for more than minimal harm 2024-12-13

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-01-27

D · Potential for more than minimal harm 2024-12-13

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-01-27

D · Potential for more than minimal harm 2024-12-13

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-01-27

D · Potential for more than minimal harm 2024-12-13

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-01-27

D · Potential for more than minimal harm 2024-12-13

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-01-27

D · Potential for more than minimal harm 2023-10-13

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-11-21

D · Potential for more than minimal harm 2023-10-13

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-11-21

D · Potential for more than minimal harm 2023-10-13

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-11-21

D · Potential for more than minimal harm 2023-08-24

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-10-08

F · Potential for more than minimal harm 2023-06-08

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-07-27

E · Potential for more than minimal harm 2023-06-08

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2023-07-23

E · Potential for more than minimal harm 2023-06-08

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2023-05-02

E · Potential for more than minimal harm 2023-06-08

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-07-23

E · Potential for more than minimal harm 2023-06-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-07-23

E · Potential for more than minimal harm 2023-06-08

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2023-07-27

D · Potential for more than minimal harm 2023-06-08

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2023-07-23

D · Potential for more than minimal harm 2023-06-08

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2023-07-23

E · Potential for more than minimal harm 2020-01-31

F700 · Quality of Life and Care Deficiencies

Health

Try 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.

Corrected 2020-03-15

E · Potential for more than minimal harm 2020-01-31

F923 · Environmental Deficiencies

Health

Have enough outside ventilation via a window or mechanical ventilation, or both.

Corrected 2020-03-15

D · Potential for more than minimal harm 2020-01-31

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2020-03-15

D · Potential for more than minimal harm 2020-01-31

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2020-03-15

D · Potential for more than minimal harm 2020-01-31

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2020-03-15

D · Potential for more than minimal harm 2020-01-31

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2020-03-15

D · Potential for more than minimal harm 2020-01-31

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2020-03-15

D · Potential for more than minimal harm 2020-01-31

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2020-03-15

D · Potential for more than minimal harm 2020-01-31

F761 · Pharmacy Service Deficiencies

Health

Ensure 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.

Corrected 2020-03-15

D · Potential for more than minimal harm 2020-01-31

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2020-03-15

Penalties and ownership