Inspection Reports for
Diversicare of Brookhaven

CI MS #3049970 was investigated related to quality of care regarding call lights not answered in a timely manner and lack of provision of water. The SA determined the facility was in compliance with no deficiencies cited.

The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

CI MS #3049970 was investigated related to quality of care regarding call lights not answered in a timely manner and lack of provision of water. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

The State Agency is recommending that the facility be placed back in compliance effective 02/09/26. No deficiencies were cited in this desk review.

The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies included failure to develop comprehensive care plans for PTSD and oxygen therapy, lack of physician orders for oxygen administration, inadequate activities programming, unsanitary food handling and storage practices, and improper infection control during medication administration.

The facility was found not in compliance with state licensure requirements due to deficiencies in the activity program, safe food handling procedures, and infection control practices.

The facility met all applicable provisions of the 2012 Edition of the Life Safety Code and all Federal, State, and local emergency preparedness requirements. No deficiencies were cited during this survey.

The facility failed to develop comprehensive care plans for PTSD and oxygen therapy for certain residents, administer oxygen without physician orders, provide activities tailored to residents' psychosocial needs, maintain proper food storage and sanitary kitchen practices, and ensure infection control during medication administration.

No deficiencies were cited in this desk review survey.

CI MS# not explicitly stated. The complaint survey was conducted starting 10/21/25. The facility corrected the cited deficiencies by 11/21/25. The complaint was substantiated but corrected. No new deficiencies cited in this desk review.

This document is a desk review related to a prior complaint survey. The facility corrected the cited deficiencies from the 10/21/25 survey by 11/21/25 but remained out of compliance with state licensure requirements until 12/12/25. No new deficiencies are cited in this document.

CI MS #2668465 investigated abuse allegations. Deficiency F0657 was cited related to failure to revise the care plan to address resident aggression.

F0657 - The facility failed to revise the comprehensive care plan to reflect ongoing behavioral concerns and physical aggression for one resident. The care plan lacked person-centered goals and interventions addressing repeated verbal and physical aggression toward staff.

CI MS#2668465 was investigated related to physical abuse. The SA determined the facility was in compliance with no deficiencies cited.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements; no citations were given.

The facility failed to revise the comprehensive care plan to include person-centered goals and interventions addressing repeated verbal and physical aggression by Resident #1 toward staff, despite multiple documented behavioral incidents and staff reports.

The investigation was complaint-driven based on multiple complaints from residents and representatives about lack of incontinent supplies, postponed care, and inadequate catheter and infection control management. The complaint was substantiated with findings of supply shortages, delayed care, and improper catheter care.

The facility failed to ensure residents had call lights within reach, experienced shortages of incontinence supplies causing postponed care, and did not properly manage indwelling catheter care and infection control practices, including improper handling of linens and overflowing urine collection bags.

CI MS#2633663 for Physical Environment related to inadequate supply of incontinence supplies, Quality of Care related to failure to provide or postponement of activities of daily living, and Dietary Services. Deficiencies were cited.

Four deficiencies were cited related to failure to ensure reasonable accommodations for residents, inadequate provision of incontinence supplies and care, improper infection prevention and control practices, and failure to properly manage indwelling catheter care for Resident #4.

Complaint survey conducted 6/02/25 through 6/04/25; facility found in compliance with no deficiencies cited.

The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 7/02/25.

CI MS #2563920 was investigated for Quality of Care/Treatment and abuse. The SA determined the facility was in compliance with no deficiencies cited.

The facility was found in compliance with the requirements of participation in Medicare and Medicaid and there were no deficiencies cited during this investigation.

Complaint number CI MS #2563920 was investigated for Quality of Care/Treatment and Abuse. The facility was found in compliance with no deficiencies cited.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm during this complaint investigation. No deficiencies were cited in this survey.

Two complaint investigations were conducted: CI MS #28869 related to Accidents, Nursing Services, Neglect, Inappropriate Feeding Assistance and Quality of Care/Treatment with deficiencies cited at F656 and F880; and CI MS #29097 related to Resident Abuse, Resident Rights and Quality of Care/Treatment with deficiencies cited at F550, F600, and F610.

The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited related to resident rights, abuse and neglect, investigation of alleged violations, care plan implementation, and infection prevention and control.

The complaint investigation involved allegations of failure to maintain resident dignity and privacy, verbal and physical abuse by a CNA against residents #2 and #3, inadequate investigation of abuse allegations especially for Resident #3, failure to implement care plans, and improper infection control practices. The abuse allegations included CNA #1 striking Resident #2's legs and verbally abusing Residents #2 and #3. The facility suspended CNA #1 during investigation and later returned her with training. The investigation was found unfounded due to lack of witnesses and injury, but emotional harm was documented. The facility failed to investigate Resident #3's abuse allegation thoroughly.

The facility failed to maintain resident dignity and privacy during care, protect residents from verbal, mental, and physical abuse, conduct thorough investigations of abuse allegations, implement comprehensive care plans, and follow proper infection prevention and control practices during incontinence care.

Complaint MS #27593 investigated for Quality of Care and Physical Environment issues; the facility was found in compliance with no deficiencies cited.

The surveyor determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.

The State Agency found the facility in compliance with the Life Safety Code effective 09/20/24.

The facility was found to be in compliance with the Requirements for Participation in Medicare and Medicaid and with Emergency Preparedness regulations.

K0918 - The facility failed to provide a remote manual stop station for the generator, affecting all smoke compartments. The facility had a capacity for 57 beds with a census of 55 on the day of the survey.

The State Agency is recommending that the facility be placed back in compliance effective 07/26/24. No deficiencies were cited in this desk review.

The facility was found to have multiple deficiencies including inaccurate coding of discharge assessments, failure to ensure residents rinsed their mouths after steroid inhaler use, improper storage of a resident's CPAP mask, and medication administration errors resulting in a medication error rate above 5%.

Two complaint investigations (CI MS #25465 and CI MS #25503) were conducted related to Medication Administration and Activities of Daily Living care. There were no citations related to these complaint investigations.

The facility was found not in compliance during the annual recertification survey with deficiencies in assessment accuracy, professional standards of care, respiratory care, and medication error rates. Four deficiencies were cited related to discharge coding errors, failure to ensure mouth rinsing after inhaler use, improper CPAP mask storage, and medication administration errors.

Complaint Investigations (CI), MS #25465 and CI MS #25503 were investigated for Medication Administration and Activities of Daily Living care. There were no citations related to the complaint investigations.

The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and cited M655 for failure to properly store a resident's CPAP mask when not in use.

The facility was found to meet the applicable provisions of the 2012 Edition of the Life Safety Code. No deficiencies were cited.

The facility was found to be in compliance with all applicable Federal, State and local emergency preparedness requirements.

CI MS#26995 - The complaint investigation was substantiated with no deficiencies cited as the facility was found in compliance.

The facility was found to be in compliance with Medicare and Medicaid requirements as of 05/02/24, with no deficiencies cited.

The complaint investigation found that the facility did not notify the resident's physician or resident representative when Resident #3 refused medications. The issue was substantiated based on interviews with nursing staff, the resident's daughter, hospice nurse, and the physician, as well as record reviews.

The facility failed to ensure the physician and resident representative were notified when Resident #3 refused medications on multiple occasions. Interviews and record reviews confirmed lack of notification despite facility policy requiring notification after two days of medication refusal.

Four complaint investigations were conducted: CI MS #23496 (neglect and medications not given), CI MS #23877 (resident rights), CI MS #24037 (resident safety and assessment), and CI MS #24438 (falls and not following physician orders). Deficiency F0580 was cited related to CI MS #23496.

The facility was found not in compliance due to failure to notify the physician and resident representative when a resident refused medications, specifically Resident #3 who refused Albuterol Sulfate treatments without proper notification documented.

Complaint survey completed on 08/31/23 was reviewed and the facility was found in compliance; no deficiencies cited.

The facility was found in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The SA is recommending that the facility be placed back in compliance effective 10/03/23.

Complaint investigations CI MS #22852 and CI MS #22803 were conducted regarding resident abuse and failure to notify a Resident Representative of a change in condition, and a resident being left wet for an extended period. The facility was found in compliance with these complaints.

The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements related to CI MS #22852 and CI MS #22803. However, the facility remains out of compliance due to deficiencies cited on 8/31/23.

Complaint investigations CI MS #22852 and CI MS #22803 were conducted related to resident abuse and notification issues; both complaints were determined to be in compliance with no deficiencies cited.

The facility was found in compliance with the requirements for participation in Medicare and Medicaid related to CI MS #22852 and CI MS #22803. However, the facility remains out of compliance due to deficiencies cited on 8/31/23.

CI MS #22186 was investigated for resident abuse and cited F550. CI MS #22227 was investigated related to dietary services, quality of care related to treatment, resident abuse, and resident rights; F584 was cited. No deficiencies were cited related to CI MS #22230 for quality of care related to incontinent care and accidents/falls.

The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited for failure to ensure resident rights by staff using foul language in the presence of a resident and failure to maintain a safe, clean, comfortable, and homelike environment in resident rooms.

The complaint involved inappropriate speech and use of foul language by CNA #1 towards Resident #1. The complaint was substantiated as CNA #1 was observed using profane language and was terminated. Additional concerns about environmental cleanliness were also investigated.

The facility failed to ensure residents were treated with respect, as evidenced by CNA #1 using foul language in the presence of residents, leading to the CNA's termination. Additionally, the facility failed to maintain a safe, clean, and comfortable environment for residents, with observations of dust, debris, and sticky floors in resident rooms.

Complaint MS #21006 regarding Physical Environment related to no hot water was investigated and found to be unsubstantiated; no deficiencies were cited.

The facility was found in compliance with the Mississippi Regulation for Minimum Standards for Institutions for the Aged or Infirm and no deficiencies were cited.

Complaint MS #21006 investigated for Physical Environment related to no hot water; the facility was found in compliance and no deficiencies were cited.

The facility was found in compliance with the requirements for participation in Medicare and Medicaid. No deficiencies were cited.

The State Agency is recommending that the facility be placed back in compliance effective 01/05/23. No deficiencies were cited in this desk review.

The facility was found deficient in multiple areas including failure to administer influenza vaccination timely, failure to obtain required PASRR Level II screening for a resident with serious mental illness, improper storage of medication leading to potential overdose risk, failure to properly sanitize cookware, and malfunctioning resident call light system.

The facility was found not in compliance with Mississippi State minimum standards, with deficiencies in residents' rights, medication policies and procedures, dishwashing sanitation, and the call system functionality.

The facility was found not in compliance with Medicare and Medicaid participation requirements with deficiencies cited in self-determination, PASARR coordination, medication storage, food sanitation, and resident call system.

The facility was found in compliance with all emergency preparedness requirements. No deficiencies were cited.

Three complaints were investigated: MS #19576 for Infection Control, MS #19492 for Quality of Care related to medications, grooming, notification, and incontinent care, and MS #19439 for Quality of Care related to assessment, feeding assistance, and fall prevention. None were substantiated and no deficiencies were cited.

The State Agency determined the facility was in compliance with the Mississippi Regulations for Minimum Standards of Institutions for the Aged or Infirm and cited no deficiencies.

Complaints MS #19576 (Infection Control), MS #19492 (Quality of Care related to medications, grooming, notification, and incontinent care), and MS #19439 (Quality of Care related to assessment, feeding assistance, and fall prevention) were investigated and not substantiated; no deficiencies were cited.

The surveyor determined the facility was in compliance with Medicare and Medicaid requirements and cited no deficiencies.

Complaint MS #18435 involved an alleged elopement incident; the complaint was not substantiated and no deficiencies were cited.

The facility was found in compliance with Medicare and Medicaid requirements. No deficiencies were cited and the reported incident for an elopement was not substantiated.

Complaint numbers MS #18314 and MS #17926 involved allegations of dirty bathrooms, lack of heating system, and infection control due to a scabies outbreak. The complaints were not substantiated and no deficiencies were cited.

The facility was found in compliance with Medicare and Medicaid requirements. The complaints regarding dirty bathrooms, lack of heating system, and infection control due to a scabies outbreak were not substantiated and no deficiencies were cited.

CI MS #16635: The investigation was unsubstantiated with no deficiencies cited for Physical Environment related to Infection Control Practices Not Followed. CI MS #16949: The investigation was unsubstantiated with no deficiencies cited for Resident Neglect.

The facility was found in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm, state licensure requirements. Both complaint investigations were unsubstantiated with no deficiencies cited.

Complaint Investigation CI MS#16635 was unsubstantiated with no deficiencies cited for Physical Environment related to Infection Control Practices Not Followed. Complaint Investigation CI MS#16949 was unsubstantiated with no deficiencies cited for Resident Neglect.

The facility was found to be in compliance with infection control regulations and no deficiencies were cited. The complaints investigated were unsubstantiated.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The facility was found not in compliance with Medicare and Medicaid requirements, with deficiencies cited in assessment accuracy, nurse aide certification, and infection prevention and control. No Life Safety Code deficiencies were cited, and the facility met emergency preparedness requirements.

Two deficiencies were cited related to accuracy of assessments and proper storage of drugs and biologicals. The facility failed to accurately code Minimum Data Set (MDS) assessments for two residents and failed to properly store medications, including expired drugs found in the medication room.