Inspection Reports for
Diversicare of Brookhaven
519 Brookman Drive, Brookhaven, MS, 39601
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
5.2 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
37% worse than Mississippi average
Mississippi average: 3.8 deficiencies/year
Deficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 5
Date: Jan 8, 2026
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care plans, oxygen therapy orders, activity provision, food safety, and infection control practices at Diversicare of Brookhaven.
Findings
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.
Deficiencies (5)
F 0656: The facility failed to develop a comprehensive care plan for PTSD and oxygen therapy for two residents, resulting in incomplete care guidance.
F 0658: The facility failed to obtain a physician order for oxygen before administering it to one resident, violating medication order protocols.
F 0679: The facility failed to provide activities and invitations that met the psychosocial needs of one resident, limiting engagement opportunities.
F 0812: The facility failed to store food properly and maintain sanitary kitchen practices, including unlabeled milk and poor hand hygiene by staff.
F 0880: The facility failed to ensure infection control during medication administration, including lack of glove use and improper disinfection of medication surfaces.
Report Facts
Residents reviewed for care plans: 20
Residents reviewed for oxygen: 2
Residents sampled for activities: 17
Residents observed for medication pass: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Observed failing to use gloves and proper hand hygiene during medication administration. | |
| Director of Nursing (DON) | Provided statements confirming care plan and infection control deficiencies. | |
| Registered Nurse (RN) #1 / Minimum Data Set (MDS) nurse | Provided information about care plan development and oxygen therapy orders. | |
| Activities Supervisor (AS) | Acknowledged failure to invite resident to activities tailored to psychosocial needs. | |
| Dietary Manager (DM) | Acknowledged poor hand hygiene and food storage practices in the kitchen. | |
| Dietary Aide (DA) | Acknowledged placing used water pitchers back on shelves with clean dishes. |
Inspection Report
Deficiencies: 1
Date: Nov 24, 2025
Visit Reason
The inspection was conducted to assess compliance with care plan requirements, specifically to determine if the facility revised the comprehensive care plan to reflect ongoing behavioral concerns and physical aggression of a resident.
Findings
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.
Deficiencies (1)
F 0657: The facility failed to develop and revise the comprehensive care plan within 7 days of the assessment to include culturally component goals and interventions for mood, behaviors, trauma history, and cognitive concerns for Resident #1. The care plan did not document person-centered goals addressing Resident #1's repeated verbal and physical aggression toward staff.
Report Facts
Behavioral incidents: 5
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | Multiple CNAs reported Resident #1's physical aggression | |
| Registered Nurse #1 | Aware of behavior concerns but had not witnessed them | |
| Interim Director of Nursing | Confirmed care plan and Kardex must include behavior issues to guide staff |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 18, 2025
Visit Reason
The inspection was conducted due to complaints regarding inadequate resident care, including failure to accommodate resident needs, lack of incontinent supplies, and infection control issues.
Complaint Details
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.
Findings
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.
Deficiencies (3)
F 0558: The facility failed to ensure call lights were within reach for two residents, limiting their ability to summon assistance.
F 0690: The facility failed to provide adequate incontinent supplies for four residents, resulting in postponed care and resident discomfort.
F 0880: The facility failed to implement proper infection prevention and control, including improper handling of linens and failure to empty overflowing urine collection bags for one resident.
Report Facts
Residents sampled: 6
Residents affected: 2
Residents affected: 4
Urinals filled: 3
Square feet urine spill: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #5 | CNA | Named in findings related to call light accessibility and catheter care |
| Licensed Practical Nurse #1 | LPN | Named in findings related to call light accessibility and catheter care |
| Human Resource Coordinator | HRC | Named in findings related to incontinence supply access and management |
| Assistant Director of Nurses | ADON | Named in infection control and catheter care supervision |
| Administrator | Named in multiple interviews confirming findings and supervisory roles | |
| Corporate Nurse Consultant | Confirmed lack of physician order for indwelling catheter |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jun 4, 2025
Visit Reason
The inspection was conducted based on complaints alleging failure to protect residents' dignity and privacy, verbal and physical abuse by staff, inadequate investigation of abuse allegations, failure to implement care plans, and improper infection control practices.
Complaint Details
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.
Findings
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.
Deficiencies (5)
F 0550: The facility failed to ensure dignity and privacy for three residents during incontinence care and feeding assistance, including exposing a resident's perineal area with window curtains open and not covering a catheter bag.
F 0600: The facility failed to protect two residents from verbal, mental, and physical abuse by a CNA who struck a resident's legs and scolded residents during incontinence care, causing emotional distress and fear.
F 0610: The facility failed to conduct a thorough investigation of verbal and mental abuse allegations reported by a resident, neglecting follow-up and psychosocial support.
F 0656: The facility failed to implement a care plan intervention requiring a resident to eat meals in the dining room as a fall prevention measure.
F 0880: The facility failed to follow hand hygiene practices during incontinence care for a resident, including not changing gloves or performing hand hygiene before applying a clean brief.
Report Facts
Residents sampled: 4
Residents affected: 3
Residents affected: 2
BIMS score: 14
BIMS score: 8
Admission dates: Apr 5, 2024
Admission dates: May 9, 2025
Admission dates: Mar 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in findings of verbal, mental, and physical abuse of Residents #2 and #3 |
| CNA #3 | Certified Nurse Aide | Observed providing incontinence care with privacy failures |
| CNA #5 | Certified Nurse Aide | Observed providing incontinence care with privacy failures and feeding assistance |
| CNA #7 | Certified Nurse Aide | Interviewed regarding care plan implementation for Resident #1 |
| Director of Nursing Services | Director of Nursing Services | Provided interviews regarding facility policies and abuse investigations |
| Administrator | Facility Administrator | Provided interviews regarding abuse allegations and investigation outcomes |
| Social Services and Admissions Liaison | Social Services and Admissions Liaison | Interviewed regarding abuse allegations and investigation follow-up |
| Former Assistant Director of Nursing Services | Assistant Director of Nursing Services | Interviewed regarding abuse allegations and investigations |
| District Ombudsman | District Ombudsman | Reported receipt of abuse allegations from resident representative |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 20, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident assessments, medication administration, respiratory care, and infection control at Diversicare of Brookhaven.
Findings
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%.
Deficiencies (4)
F 0641: The facility failed to correctly code a discharge on the Discharge Minimum Data Set Assessment for one of 14 sampled residents, resulting in inaccurate resident discharge data.
F 0658: The facility failed to ensure a resident rinsed her mouth after administration of a steroid Metered-Dose Inhaler, increasing risk of mouth and throat irritation.
F 0695: The facility failed to ensure a resident's CPAP mask was properly stored when not in use, risking contamination and respiratory infection.
F 0759: The facility failed to maintain a medication error rate below 5%, with two medication errors observed out of 27 opportunities, involving incorrect dosing and failure to instruct mouth rinsing after inhaler use.
Report Facts
Medication error rate: 7.4
Sampled residents for discharge assessment: 14
Medication errors observed: 2
Medication administration opportunities: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Failed to instruct Resident #32 to rinse mouth after Symbicort inhaler administration. |
| Licensed Practical Nurse #2 | LPN | Administered incorrect dose of Flonase nasal spray to Resident #25. |
| Licensed Practical Nurse #3 | LPN | Explained proper storage of CPAP mask to prevent infection. |
| Director of Nursing | DON | Confirmed expectations for accurate MDS coding and medication administration. |
| Nurse Practitioner #1 | NP | Explained expectations for following physician orders and medication administration. |
| Nurse Practitioner #2 | NP | Explained expectations for staff to follow physician orders for Flonase administration. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 21, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to notify the physician and resident representative when a resident refused to take medications.
Complaint Details
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.
Findings
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.
Deficiencies (1)
F 0580: The facility failed to notify the physician and resident representative when Resident #3 refused Albuterol Sulfate HFA Aerosol treatments on 12/1/23, 12/2/23, and 12/3/23. There was no documentation of notification despite policy requiring it after two days of refusal.
Report Facts
Residents affected: 1
Medication refusal dates: 3
BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding notification policy and medication refusal |
| RN #2 | Registered Nurse | Interviewed regarding notification and documentation of medication refusal |
| RN #3 | Hospice Nurse | Interviewed about hospice visits and notification practices |
| RN #4 | Hospice Nurse | Interviewed about notification of resident refusals |
| Director of Nurses | Director of Nursing | Interviewed about facility policy on medication refusal notification |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 31, 2023
Visit Reason
The inspection was conducted following a complaint regarding inappropriate speech and use of foul language by a Certified Nursing Assistant (CNA) towards a resident, and concerns about the cleanliness and safety of the environment for residents.
Complaint Details
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.
Findings
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.
Deficiencies (2)
F 0550: The facility failed to honor the resident's right to a dignified existence and respect, as CNA #1 used foul language in the presence of Resident #1 and was subsequently terminated for misconduct.
F 0584: The facility failed to provide a safe, clean, and homelike environment for Residents #3 and #4, with observations of dust, debris, sticky floors, and inadequate cleaning practices.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in findings related to use of foul language and termination for misconduct. |
| Administrator | Interviewed regarding CNA #1's behavior and termination. | |
| Occupational Therapist | Occupational Therapist | Reported the incident of inappropriate language by CNA #1. |
| Social Worker | Social Worker | Interviewed regarding observations of Resident #1 after the incident. |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding cleaning practices and observations of dirty and sticky floors. |
Inspection Report
Routine
Deficiencies: 5
Date: Dec 1, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, PASRR screening, food sanitation, and call system functionality at Diversicare of Brookhaven.
Findings
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.
Deficiencies (5)
F 0561: The facility failed to honor a resident's right to choose health care by not administering the requested influenza vaccination upon admission for one resident. The delay was due to dependency on the Director of Nursing to print vaccination consents.
F 0644: The facility failed to ensure a PASRR Level II was obtained for a resident after diagnosis of a serious mental disorder, risking inappropriate placement and care.
F 0761: The facility failed to store Flonase medication in a locked compartment, leaving it on a resident's bedside table, risking possible overdose due to resident's cognitive impairment.
F 0812: The facility failed to ensure cookware was properly sanitized as the chemical sanitizer in the three-compartment sink measured zero ppm instead of the required 100-200 ppm, risking resident illness.
F 0919: The facility failed to maintain a properly functioning call system for one hall, as call lights were on but no audible sound was heard, compromising resident ability to notify staff.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 55
Residents affected: 1
Medication administration delay timeframe: 14
Sanitizer concentration: 0
Sanitizer container volume: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #3 | Infection Preventionist | Confirmed vaccination consent process and delay |
| Director of Nursing | Director of Nursing | Confirmed dependency on printing vaccination consents and call system issues |
| Licensed Practical Nurse #1 | Medical Records Nurse/LPN | Administers vaccinations and confirmed delay due to consent printing |
| Registered Nurse #2 | RN | Confirmed medication left on bedside table |
| Registered Nurse #1 | RN | Confirmed medication storage issue and uncertainty about extra doses |
| Dietary Manager | Dietary Manager | Observed sanitizer concentration and explained filter issue |
| Administrator | Administrator | Confirmed call system issues and replacement of control box |
| Maintenance Director | Maintenance Director | Replaced call system control box and confirmed repair |
| Pharmacy Consultant | Pharmacy Consultant | Confirmed medication should be observed and stored properly |
Viewing
Loading inspection reports...
