Inspection Reports for
Trend Health & Rehab of Brookhaven, LLC
525 Brookman Drive, Brookhaven, MS, 39601
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Inspection Report — Oct 10, 2024
Routine CMS
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 — Aug 29, 2023
CMS
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 — Mar 9, 2023
Routine CMS
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 — Aug 8, 2019
Routine CMS
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 |
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