Inspection Reports for
Trend Health & Rehab of Brookhaven, LLC
525 Brookman Drive, Brookhaven, MS, 39601
Back to Facility Profile37 Reports
Inspection Report — Mar 16, 2026
Annual Inspection
Date: Mar 16, 2026
Visit Reason
On 03/16/26 the State Agency (SA) conducted a desk review of the information that was provided related to the annual survey completed on 02/12/26. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The SA is recommending that the facility be placed back in compliance effective 03/11/26. No deficiencies were cited in this desk review.
Inspection Report — Feb 12, 2026
Life Safety
Date: Feb 12, 2026
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met all applicable provisions of the 2012 Edition of the Life Safety Code. No deficiencies were cited during this survey.
Inspection Report — Feb 12, 2026
Annual Inspection
Date: Feb 12, 2026
Visit Reason
The State Agency conducted an annual recertification survey and Complaint Investigation (CI MS# 2712196) from 2/9/26 through 2/12/26. CI MS # 2712196 was investigated for accident hazards and cited F0689. During the survey, the facility was found not in compliance with Medicare and Medicaid participation requirements and cited F0656, F0689, F0759, F0761, F0812, F0880.
Complaint Details
CI MS# 2712196 was investigated for accident hazards and cited F0689.
Findings
The facility was found not in compliance with multiple requirements including failure to follow comprehensive care plans for safe mechanical lift transfers, medication errors due to unavailable medications, unsecured emergency medication kit, improper food labeling and dating, and inadequate infection prevention practices including poor hand hygiene during care.
Deficiencies (6)
F0656 - The facility failed to ensure staff followed the resident's comprehensive care plan and facility mechanical lift policy for safe transfers for one resident, resulting in a fall when a CNA lifted Resident #30 alone despite care plan requiring two staff.
F0689 - The facility failed to ensure safe transfer practices by not having two staff present during a mechanical lift transfer for one resident, resulting in a fall and injury.
F0759 - The facility failed to ensure medications were available for administration as ordered for two residents, resulting in a medication error rate of 6.9%.
F0761 - The facility failed to ensure the emergency medication kit was secured and locked to prevent unauthorized access and ensure availability of medications for emergency use.
F0812 - The facility failed to ensure food items were properly dated and labeled in accordance with food storage guidelines, risking use of food beyond recommended time frames.
F0880 - The facility failed to ensure staff performed hand hygiene according to infection prevention standards before donning gloves, after glove removal, and after contact with contaminated surfaces during medication administration and enteral feeding for three residents.
Report Facts
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
Inspection Report — Feb 12, 2026
Annual Inspection
Date: Feb 12, 2026
Visit Reason
The State Agency conducted an annual recertification survey and Complaint Investigation (CI MS# 2712196) from 2/9/26 through 2/12/26. CI MS # 2712196 was investigated for accident hazards and cited M640. During the survey, the facility was found not in compliance with state licensure requirements and cited M815 and M1570.
Complaint Details
CI MS# 2712196 was investigated for accident hazards and cited M640. The complaint was substantiated with deficiencies cited.
Findings
The facility was found not in compliance with state licensure requirements due to failure to ensure safe transfer practices, failure to store food under sanitary conditions, and failure to follow infection control procedures during medication administration and wound care.
Deficiencies (3)
M0640 - The facility failed to ensure two staff members were present during mechanical lift transfers, resulting in a resident falling when lifted alone by one CNA.
M0815 - The facility failed to store prepared food items properly by not labeling and dating food containers in the kitchen refrigerator.
M1570 - The facility failed to maintain effective infection control by not performing proper hand hygiene and glove changes during medication administration and wound care for multiple residents.
Report Facts
Deficiencies cited: 3
Inspection Report — Nov 25, 2025
Complaint Investigation
Date: Nov 25, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2646008 at the facility from 11/24/25 through 11/25/25 related to coordination of care with the facility and hospice services.
Complaint Details
CI MS#2646008 was investigated related to coordination of care with the facility and hospice services. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The facility was found to be in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — Nov 26, 2024
Follow-Up
Date: Nov 26, 2024
Visit Reason
The State Agency conducted a revisit survey at the facility on 11/26/24 related to a complaint survey that was conducted on 10/22/24.
Findings
The survey determined that the facility was in compliance with the requirements of the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. The facility was recommended to be placed back in compliance effective 11/19/24.
Inspection Report — Nov 2, 2024
Annual Inspection
Date: Nov 2, 2024
Visit Reason
On 11/2/24 the State Agency (SA) conducted a desk review of the information that was provided related to the annual survey completed on 10/10/24. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 11/01/24. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Oct 10, 2024
Routine
Date: Oct 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, environment, and dietary services at Trend Health and Rehab of Brookhaven.
Findings
The facility was found deficient in maintaining a clean and homelike environment for a resident's room, failing to implement care plan interventions regarding PPE and hand hygiene for residents with PEG tubes, not providing a physician-ordered salad to a resident, and not ensuring proper infection control practices during care for residents on Enhanced Barrier Precautions.
Deficiencies (4)
F 0584: The facility failed to ensure a resident's right to a safe, clean, and homelike environment as evidenced by a soiled privacy curtain, missing paint on walls, strong odors, and flies in Resident #14's room.
F 0656: The facility failed to implement care plan interventions regarding wearing all PPE during perineal care and hand hygiene during PEG tube care for Residents #24 and #40.
F 0800: The facility failed to ensure Resident #44 received a physician-ordered side salad with ranch dressing during lunch meals as ordered.
F 0880: The facility failed to ensure proper infection control practices during care for Residents #24 and #40 on Enhanced Barrier Precautions, including hand hygiene and wearing required gowns.
Report Facts
Residents sampled: 18
Residents reviewed for care: 5
Residents affected: 1
Residents affected: 2
Residents affected: 1
Flies observed: 4
BIMS score: 9
BIMS score: 15
BIMS score: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Observed failing to perform hand hygiene before PEG tube care for Resident #24 and admitted the error. |
| CNA #1 | Certified Nursing Assistant | Observed providing perineal care without wearing required gown for Resident #40 and admitted the error. |
| LPN #5 | Care Plan Nurse | Confirmed care plans should be followed and acknowledged staff noncompliance for Residents #24 and #40. |
| Director of Nursing | Director of Nursing (DON) | Confirmed residents were on Enhanced Barrier Precautions and acknowledged failures in care plan adherence and infection control. |
| Housekeeping Staff #1 | Housekeeping Staff | Confirmed presence of flies, odor, stained privacy curtain, and missing paint in Resident #14's room. |
| Dietary Manager | Dietary Manager | Acknowledged failure to update Resident #44's food preferences and unawareness of physician's order for salads. |
| Registered Dietician | Registered Dietician (RD) | Explained process of communicating nutritional assessments and diet orders for Resident #44. |
| LPN #4 | Infection Preventionist | Confirmed infection control breaches by LPN #3 and CNA #1 during care of Residents #24 and #40. |
Inspection Report — Oct 10, 2024
Annual Inspection
Date: Oct 10, 2024
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 10/7/2024 through 10/10/2024. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F584, F656, F800 and F880.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies in maintaining a safe and homelike environment, implementing comprehensive care plans, meeting dietary needs, and infection prevention and control.
Deficiencies (4)
F0584 - Safe/clean/comfortable/homelike environment. The facility failed to ensure a resident's right to a clean, comfortable, and homelike environment as evidenced by a soiled privacy curtain, missing paint on the walls, strong odors, and flies present in the resident's room for one of fourteen sampled residents (Resident #14).
F0656 - Develop/implement comprehensive care plan. The facility failed to implement care plan interventions regarding wearing all Personal Protective Equipment (PPE) during perineal care and hand hygiene during PEG tube care for two of five residents reviewed for care (Residents #24 and #40).
F0800 - Provided diet meets needs of each resident. The facility failed to ensure a resident received a physician-ordered salad during the lunch meal for one of eighteen sampled residents (Resident #44).
F0880 - Infection prevention and control. The facility failed to ensure proper infection control practices during the provision of care for residents on Enhanced Barrier Precautions for two of five care observations (Residents #24 and #40).
Report Facts
Deficiencies cited: 4
Inspection Report — Oct 10, 2024
Annual Inspection
Date: Oct 10, 2024
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 10/7/2024 through 10/10/2024. During the survey, the SA determined the facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and cited M855, M1020, and M1570.
Findings
The facility was found not in compliance with state licensure requirements due to failures in food preparation, maintaining a clean and homelike environment in resident bedrooms, and infection control practices during care for residents on Enhanced Barrier Precautions.
Deficiencies (3)
M855 - Food Preparation. The facility failed to ensure a resident received a physician-ordered salad during the lunch meal for one of eighteen sampled residents, despite the resident's repeated requests and a physician's order.
M1020 - Resident Bedrooms. The facility failed to maintain a clean, comfortable, and homelike environment in one resident's room, evidenced by a soiled privacy curtain, missing paint on walls, strong odors, and presence of flies.
M1570 - Infection Control. The facility failed to ensure proper infection control practices during care for residents on Enhanced Barrier Precautions, including failure to perform hand hygiene and improper use of personal protective equipment by staff.
Report Facts
Deficiencies cited: 3
Inspection Report — Oct 8, 2024
Life Safety
Date: Oct 8, 2024
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility was found to meet the applicable provisions of the 2012 Edition of the Life Safety Code. No deficiencies were cited.
Inspection Report — Dec 18, 2023
Routine
Date: Dec 18, 2023
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network.
Findings
The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period. This failure had the potential to cause more than minimal harm to all residents.
Deficiencies (1)
F0884 - The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 10, 2023
Complaint Investigation
Date: Oct 10, 2023
Visit Reason
On 10/10/23 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 08/29/23. The facility confirmed corrective measures were in place and compliance was sustained.
Complaint Details
Complaint survey completed on 08/29/23; the facility was found in compliance with no deficiencies cited.
Findings
The State Agency found the facility in compliance and recommended it be placed back in compliance effective 10/04/23. No deficiencies were cited.
Report Facts
Complaint survey date: 08/29/2023
Inspection Report — Aug 29, 2023
Date: Aug 29, 2023
Visit Reason
The inspection was conducted to assess compliance with food quality and palatability standards in the facility.
Findings
The facility failed to serve meals that were palatable for two of three residents reviewed. Observations, interviews, and record reviews confirmed that some meals were bland and lacked seasoning, impacting resident satisfaction.
Deficiencies (1)
F 0804: Ensure food and drink is palatable, attractive, and served at a safe and appetizing temperature. The facility failed to serve palatable meals to two of three residents reviewed, with reports of bland food lacking seasoning.
Inspection Report — Aug 29, 2023
Complaint Investigation
Date: Aug 29, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #22256 and MS #22183, at the facility from 8/28/23 through 8/29/23. MS #22256 was investigated related to Quality of Care regarding incontinent care and hydration. MS #22183 was investigated regarding Dietary Services regarding meal preparation, therapeutic diets, and palatable meals.
Complaint Details
Complaint Investigation MS #22256 related to Quality of Care regarding incontinent care and hydration found no deficiencies. Complaint Investigation MS #22183 related to Dietary Services regarding meal preparation, therapeutic diets, and palatable meals resulted in one deficiency cited for food preparation.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. No deficiencies were cited for incontinent care and hydration. However, a deficiency was cited for food preparation related to palatability.
Deficiencies (1)
M855 - Food Preparation. The facility failed to serve meals that were palatable for two of three residents reviewed, with residents reporting bland tasting food and lack of seasoning on multiple occasions.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 29, 2023
Complaint Investigation
Date: Aug 29, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #22256 and MS #22183, at the facility from 8/28/23 through 8/29/23. CI MS #22256 was investigated related to Quality of Care regarding incontinent care and hydration and no deficiencies were cited. The facility was found not in compliance related to CI MS #22183 for Dietary Services regarding meal preparation, therapeutic diets, and palatable meals and cited F804.
Complaint Details
Complaint Investigation MS #22256 related to Quality of Care regarding incontinent care and hydration was not substantiated with deficiencies. Complaint Investigation MS #22183 related to Dietary Services regarding meal preparation, therapeutic diets, and palatable meals was substantiated with deficiency F804 cited.
Findings
F0804 - The facility failed to serve meals that were palatable for two of three residents reviewed. Residents reported bland food lacking seasoning, confirmed by observations and interviews with dietary staff.
Deficiencies (1)
F0804 - Nutritive value and palatability of food. The facility failed to serve meals that were palatable for two of three residents reviewed, with residents reporting bland food and dietary staff confirming lack of seasoning.
Report Facts
Deficiencies cited: 1
Inspection Report — May 1, 2023
Annual Inspection
Date: May 1, 2023
Visit Reason
On 05/01/23 the State Agency conducted a desk review of the information provided related to the annual survey completed on 03/09/23. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 04/19/23. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Mar 9, 2023
Routine
Date: Mar 9, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, medication management, infection control, and dietary services at Trend Health and Rehab of Brookhaven.
Findings
The facility failed to resolve repeated resident complaints about food quality, including cold and bland food. Expired refrigerated medications were found in storage, and infection control issues were noted due to an unattended ice chest in the hallway, potentially exposing residents to contamination.
Deficiencies (3)
F 0565: The facility failed to resolve repeated dietary complaints about food being cold, salty, and bland over five of six months of Resident Council Meeting minutes reviewed.
F 0761: The facility failed to remove expired refrigerated medications from the medication storage room during one of two observations.
F 0880: The facility failed to prevent possible infection spread by leaving an unattended ice chest in the hallway for one of four days observed.
Report Facts
Months with dietary complaints: 5
Observation days with unattended ice chest: 1
Expired medication observations: 1
Resident Council Members interviewed: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Consultant | Observed test tray and food quality on 3/6/23 | |
| Activity Director | Recorded Resident Council Meeting minutes and confirmed forwarding complaints | |
| District Manager | Confirmed resident complaints and food quality issues | |
| Administrator | Confirmed awareness of food complaints and communication with Regional Managers | |
| Dietary Manager | Aware of food complaints and efforts to improve food temperature and taste | |
| RN #2 | Registered Nurse | Observed expired medication and explained disposal responsibility |
| Director of Nursing | Director of Nursing | Confirmed responsibility for expired medication disposal and infection control issues |
| RN #3 | Registered Nurse / Infection Preventionist | Confirmed infection control issue with unattended ice chest |
| Certified Nurse Aide | Certified Nurse Aide | Should have removed ice chest from hallway after passing out ice |
Inspection Report — Mar 9, 2023
Annual Inspection
Date: Mar 9, 2023
Visit Reason
The State Agency (SA) conducted an annual re-certification survey at the facility from 03/06/23 through 03/09/23. During the survey, the SA determined the facility was not in compliance with Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and cited M865.
Findings
The facility failed to resolve repeated group dietary complaints voiced by residents during Resident Council Meetings for five of the six months reviewed. Residents consistently complained about cold, salty, and bland food, and the facility acknowledged ongoing efforts to improve food temperature and taste.
Deficiencies (1)
M865 - Serving of Meals. The facility failed to resolve repeated group dietary complaints about cold, salty, and bland food during five of six months of Resident Council Meetings reviewed.
Report Facts
Deficiencies cited: 1
Inspection Report — Mar 9, 2023
Annual Inspection
Date: Mar 9, 2023
Visit Reason
The State Agency conducted an annual re-certification survey at the facility from 03/06/23 through 03/09/23. During the survey, the SA determined the facility was not in compliance with the requirements for participation in Medicare and Medicaid and cited F565, F761 and F880.
Findings
The facility was found not in compliance with deficiencies related to resident/family group response, drug labeling and storage, and infection prevention and control. The survey identified unresolved dietary complaints, expired refrigerated medications, and infection control issues with unattended ice carts.
Deficiencies (3)
F0565 - Resident/Family Group and Response. The facility failed to resolve repeated dietary complaints voiced by residents during Resident Council Meetings for five of six months reviewed, including complaints of cold, salty, and bland food.
F0761 - Label/Store Drugs and Biologicals. The facility failed to remove expired refrigerated medications from the medication storage room, including an expired influenza vaccine.
F0880 - Infection Prevention & Control. The facility failed to prevent possible spread of infection by leaving an unattended ice chest in the hallway, which was contaminated by a resident.
Report Facts
Deficiencies cited: 3
Inspection Report — Mar 7, 2023
Life Safety
Date: Mar 7, 2023
Visit Reason
The facility underwent a Life Safety Code survey to assess compliance with the 2012 Edition of the Life Safety Code of the National Fire Protection Association (NFPA).
Findings
The facility failed to provide 20-minute fire resistance rating smoke barrier doors as required by NFPA 101, affecting two of six smoke compartments. Specifically, the F Hall smoke barrier doors did not close to a positive latching position and were incapable of resisting smoke passage.
Deficiencies (1)
K0374 - The facility failed to provide 20-minute fire resistance rating smoke barrier doors in accordance with NFPA 101, as the F Hall smoke barrier doors did not close to positive latching position and allowed smoke passage.
Report Facts
Deficiencies cited: 1
Inspection Report — Feb 2, 2023
Complaint Investigation
Date: Feb 2, 2023
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI), MS #19900 at the facility on 12/27/22.
Complaint Details
Complaint number CI MS#19900 involved allegations of cold food, insufficient food, uncooked food, or therapeutic diets and was not substantiated; no deficiencies were cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Dec 27, 2022
Complaint Investigation
Date: Dec 27, 2022
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #19900 and CI MS# 20313) at the facility on 12/27/22.
Complaint Details
Complaint numbers CI MS #19900 and CI MS# 20313 involved allegations of cold food, insufficient food, uncooked food, and therapeutic diets. The complaints were not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements. The complaints regarding cold food, insufficient food, uncooked food, or therapeutic diets were not substantiated and no deficiencies were cited.
Report Facts
Complaint Investigations: 2
Inspection Report — Nov 24, 2020
Complaint Investigation
Date: Nov 24, 2020
Visit Reason
The State Agency conducted a complaint investigation at the facility on 11/24/2020 regarding Physical Environment related to Facility Not Clean and Infection Control.
Complaint Details
CI MS #16760: Complaint investigation regarding Physical Environment related to Facility Not Clean and Infection Control. The complaint was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated with no deficiencies cited. The facility was found in compliance with Medicare and Medicaid requirements for participation.
Inspection Report — Nov 24, 2020
Routine
Date: Nov 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey along with a complaint investigation (CI MS #16760) was conducted by the State Agency (SA) on 11/24/2020.
Complaint Details
CI MS #16760: The complaint investigation was unsubstantiated with no deficiencies cited for Physical Environment related to Facility Not Clean and Infection Control.
Findings
The facility was found to be in compliance with infection control regulations and Medicare and Medicaid requirements. The complaint investigation was unsubstantiated with no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — Nov 24, 2020
Routine
Date: Nov 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 11/24/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Aug 28, 2020
Routine
Date: Aug 28, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 8/28/20.
Findings
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.
Inspection Report — Aug 28, 2020
Routine
Date: Aug 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 8/28/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Aug 5, 2020
Routine
Date: Aug 5, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 8/5/20.
Findings
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.
Inspection Report — Jun 23, 2020
Routine
Date: Jun 23, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 6/23/20.
Findings
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.
Inspection Report — Jun 23, 2020
Routine
Date: Jun 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 6/23/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jan 29, 2020
Complaint Investigation
Date: Jan 29, 2020
Visit Reason
The State Survey Agency (SA) conducted a complaint investigation on 1/29/2020 regarding Quality of Care related to pressure sores.
Complaint Details
CI MS #16474: Complaint investigation regarding Quality of Care related to pressure sores was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated with no deficiencies cited. The facility was found in compliance with Medicare and Medicaid requirements for participation.
Inspection Report — Aug 8, 2019
Routine
Date: Aug 8, 2019
Visit Reason
Routine inspection of Trend Health and Rehab of Brookhaven to assess compliance with healthcare regulations including resident care, infection control, and dietary services.
Findings
The facility was found deficient in multiple areas including failure to protect a resident from misappropriation of funds, incomplete and inaccurate resident assessments, failure to develop and implement comprehensive care plans, improper catheter and PEG tube care leading to infection control risks, failure to calibrate food thermometers and improper food handling, and inadequate hand hygiene during wound care increasing infection risk.
Deficiencies (9)
F0602: The facility failed to protect Resident #51 from misappropriation of funds by a staff member who borrowed $20 and was terminated after the funds were replaced.
F0637: The facility failed to complete a Significant Change in Status Assessment within 14 days for Resident #57 after hospice admission.
F0641: The facility failed to accurately code the Minimum Data Set related to hospice services for Residents #57 and #58.
F0656: The facility failed to implement comprehensive care plans for Residents #16, #54, and #207 related to catheter care, anticoagulant therapy, and PEG tube care.
F0657: The facility failed to revise Resident #48's care plan to address weight loss related to cancer and edema.
F0690: The facility failed to provide catheter care for Resident #16 in a manner to prevent infection and cross contamination, including improper hand hygiene and reuse of cloths.
F0693: The facility failed to provide proper PEG tube care for Resident #207, including contamination risks from handling and failure to date/initial dressings.
F0812: The facility failed to prevent foodborne illness by not calibrating food thermometers, improper food handling including stirring food with thermometer handles, and stacking wet juice glasses.
F0880: The facility failed to perform hand hygiene at appropriate times during wound care for Resident #52, causing risk of cross contamination and infection.
Report Facts
Residents reviewed for Trust Fund accounts: 4
Resident Minimum Data Set (MDS) assessments reviewed: 20
Resident care plans reviewed: 20
Juice glasses observed wet and stacked: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Named in catheter and PEG tube care infection control deficiencies |
| LPN #1 | Licensed Practical Nurse | Named in wound care hand hygiene deficiency |
| Dietary Manager | Named in food handling and thermometer calibration deficiencies | |
| RN #1 | MDS Coordinator/Care Plan Nurse | Named in care plan and MDS coding deficiencies |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies and expectations |
Inspection Report — Aug 8, 2019
Annual Inspection
Date: Aug 8, 2019
Visit Reason
The State Agency (SA) conducted an annual recertification survey along with a complaint survey for CI MS #00015773 from 8/5/19 to 8/8/19. The SA did not substantiate the complaint CI MS #0001577 related to Quality of Care-Wound Care, and did not cite any deficiencies related to the complaint. During the survey the SA determined the facility was not in compliance with the requirements of participation for Medicare and Medicaid, and also cited deficient practice at F602, F637, F641, F656, F657, F690, F693, F812, and F880. During the survey the SA investigated a Facility Reported Incident (FRI) related to misappropriation of Resident #51's funds. The SA substantiated the FRI and cited F602.
Complaint Details
Complaint investigation CI MS #00015773 related to Quality of Care-Wound Care was not substantiated and no deficiencies were cited related to the complaint.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies in areas including misappropriation of funds, assessments, care planning, catheter care, infection control, food safety, and emergency power systems. One complaint was investigated and not substantiated. The facility failed to implement proper infection control and care procedures in several instances, and lacked a required bypass isolation switch for the emergency generator.
Deficiencies (10)
F0602 - Free from Misappropriation/Exploitation. The facility failed to protect Resident #51 from misappropriation of funds by a housekeeper who borrowed $20 and did not repay it. The funds were replaced and the employee was suspended and terminated.
F0637 - Comprehensive Assessment After Significant Change. The facility failed to complete a Significant Change in Status Assessment within 14 days for Resident #57 after admission to hospice care.
F0641 - Accuracy of Assessments. The facility failed to accurately code the Minimum Data Set related to hospice services and discharge for Residents #57 and #58.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement care plans for Resident #16's suprapubic catheter care, Resident #207's PEG tube care, and failed to develop a care plan for Resident #54's anticoagulant therapy.
F0657 - Care Plan Timing and Revision. The facility failed to revise Resident #48's care plan to reflect weight loss related to cancer diagnosis and edema.
F0690 - Bowel/Bladder Incontinence, Catheter, UTI. The facility failed to provide catheter care in a manner to prevent infection and cross contamination for Resident #16.
F0693 - Tube Feeding Management/Restore Eating Skills. The facility failed to provide PEG tube site care in a manner to prevent infection and cross contamination for Resident #207.
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to prevent the spread of food borne illness during tray line temperature checks and allowed wet stacking of juice glasses. The thermometer was not calibrated and was used improperly contaminating food.
F0880 - Infection Prevention & Control. The facility failed to perform hand hygiene at appropriate times during wound care for Resident #52, increasing risk of cross contamination and infection.
K0911 - Electrical Systems - Other. The facility failed to have a properly installed bypass isolation switch for the emergency generator, preventing automatic transfer of power.
Report Facts
Deficiencies cited: 9
Inspection Report — Jun 7, 2018
Complaint Investigation
Date: Jun 7, 2018
Visit Reason
A complaint investigation was conducted on June 7, 2018 in the facility.
Complaint Details
CI MS #15231: A complaint investigation was conducted and substantiated with no deficiencies cited.
Findings
The result of the investigation was substantiated with no deficiencies cited.
Inspection Report — Dec 5, 2017
Complaint Investigation
Date: Dec 5, 2017
Visit Reason
A complaint investigation was conducted on December 5, 2017 in your facility.
Complaint Details
CI MS #14890: A complaint investigation was conducted and found unsubstantiated with no deficiencies cited.
Findings
The result of the investigation was unsubstantiated with no deficiencies cited.
Report Facts
Complaints investigated: 1
Inspection Report — Oct 19, 2017
Annual Inspection
Date: Oct 19, 2017
Visit Reason
The State Survey Agency (SA) conducted an annual recertification survey from 10/16/17 through 10/19/17. During the survey, the SA determined the facility was not in compliance with the Centers for Medicare and Medicaid Services Conditions of Participation.
Findings
The facility was found not in compliance with multiple requirements including abuse investigation, feeding assistance, accident prevention, food quality, medication administration, and infection control.
Deficiencies (8)
F0226 - The facility failed to conduct a thorough investigation and timely report an incident where Resident #17's electric wheelchair tipped over during transport to an outside facility.
F0282 - The facility failed to follow the plan of care to ensure Resident #12 received feeding assistance during meal service, leaving the resident's breakfast tray untouched for over an hour.
F0312 - The facility failed to provide feeding assistance for more than an hour after meal service to Resident #12, who was dependent on staff for feeding.
F0323 - The facility failed to ensure Resident #17 was safely transferred to an outside program, as the wheelchair was not properly secured during transport causing the resident to tip over.
F0364 - The facility failed to ensure food was prepared to maintain nutritive value and palatability, and failed to provide sufficient quantities of some food items, as evidenced by overcooked broccoli, lack of pimento cheese, jelly, and repeated menu items.
F0367 - The facility failed to ensure residents received ordered therapeutic diets and food preferences, as Resident #9 did not consistently receive meals when at dialysis.
F0431 - The facility failed to label and store medications correctly, resulting in medications for Resident #1 being labeled for oral administration while ordered to be given via PEG tube.
F0441 - The facility failed to prevent the spread of infection by not cleaning the multi-use glucometer after resident use, as observed with Resident #14.
Report Facts
Deficiencies cited: 8
4 CMS Surveys
CMS Survey — Aug 29, 2023
Aug 29, 2023
CMS Survey — Aug 8, 2019
Aug 8, 2019
CMS Survey — Mar 9, 2023
Mar 9, 2023
CMS Survey — Oct 10, 2024
Oct 10, 2024
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