Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Diversicare Of Brookhaven during CMS and state inspections, most recent first.
Failure to Obtain Physician Order for Oxygen: A resident with unspecified asthma was observed receiving O2 at 2 ml while in bed, but the active order summary did not include a physician order for oxygen. The facility’s policy states oxygen is a drug and must be provided with a healthcare provider’s order, and the DON confirmed there were no standing orders and that oxygen should not be given without a physician order.
Food was not stored and handled according to professional standards during kitchen observations. A cup of thickened milk in a refrigerator was unlabeled and undated, and staff were observed with poor hand hygiene and cross-contamination practices, including touching a garbage can lid and then clean dishes, handling ready-to-eat cornbread with bare hands, touching the mouth and then a food thermometer, and placing used water pitchers back with clean dishes. The DM and Administrator acknowledged the issues and the importance of sanitation.
The facility failed to develop a comprehensive care plan for a resident with chronic PTSD and failed to develop a care plan for another resident receiving oxygen therapy. Staff interviews confirmed PTSD details and oxygen use should be included in care plans so staff would know how to provide care, but the records showed no PTSD care plan for one resident and no oxygen care plan for the other. The resident with PTSD had dementia with mood disturbance and moderate cognitive impairment, while the resident receiving oxygen had asthma and was observed on oxygen without a physician order in the active record.
Failure to Invite Resident to Activities: A cognitively intact resident admitted for rehab with COPD was not offered activity invitations that matched his preferences, despite his assessment listing Bingo and his request for one-on-one activities. Staff were observed inviting other residents to scheduled activities while passing his room, and the resident confirmed he was not invited to any activities that day, including Bingo. The AS and Administrator acknowledged the missed invitations.
An LPN failed to follow infection control practices during a medication pass for a resident with COPD and intact cognition. The nurse placed medications on the bedside table without disinfecting the surface or using a barrier, administered a nasal spray, inhaler, and lidocaine patch without gloves or hand hygiene between routes, and returned used items to the med cart without disinfecting them. The DON confirmed gloves, hand hygiene, and surface disinfection were required.
The facility failed to update a resident’s comprehensive care plan to reflect ongoing verbal and physical aggression toward staff. The resident had diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety, and the MDS coded behavioral symptoms directed toward others. Multiple CNAs reported being hit, kicked, grabbed, or otherwise assaulted by the resident, and the RN and Interim DON confirmed that behavior concerns should be included in the care plan used by staff to direct care.
Incontinence Care and Catheter Maintenance Deficiencies: A facility failed to provide timely incontinent care and briefs for several residents, with staff and residents reporting repeated shortages, delayed access to supplies, and postponed care while waiting for briefs or a key to the supply room. A resident with an indwelling urinary catheter was found with a full, overflowing drainage bag lying on the floor, urine on the floor around the bed, and no documented physician order for the catheter; a nurse said catheter care had not been provided or verified.
A CNA transported a stack of clean linen down the hallway without covering it, despite knowing linens should be covered during transport. In addition, a resident with an indwelling catheter, severe cognitive impairment, and a history of UTI had an overflowing urine collection bag and cover, with urine dripping onto the floor and the room smelling strongly of urine; the ADON/IP confirmed the bag had not been emptied and that catheter drainage systems should be monitored and emptied as needed.
A facility failed to keep call lights within reach for two residents. One resident, who was cognitively intact, could not reach the call light because it was attached to the opposite side of the bed from his wheelchair, and another resident’s call light was coiled on the floor behind the bed while the resident rested in bed. The Administrator, CNA, and LPN all confirmed the call lights were out of reach.
Two residents experienced verbal, mental, and physical abuse from a CNA during incontinence care, including being struck, scolded, and berated for incontinence. Both residents, one cognitively intact and one with moderate impairment, reported feeling afraid, humiliated, and emotionally distressed as a result of the CNA's actions, which were corroborated by staff interviews and facility records.
Staff failed to maintain resident dignity and privacy by providing incontinence care with an open window curtain, leaving a catheter drainage bag uncovered, and assisting a resident with meals while standing over them instead of sitting at their side. These actions did not follow facility policies requiring privacy and respectful care.
A resident with moderate cognitive impairment, who was always incontinent and required significant assistance, reported being scolded by a CNA for wetting the bed, resulting in feelings of shame and fear. Although the incident was reported to nursing leadership, no comprehensive investigation, follow-up, or psychosocial support was provided, and the CNA was not questioned about this specific allegation.
A resident with Alzheimer's Disease and severely impaired cognitive skills was not provided meals in the dining room as required by her care plan for fall prevention. Instead, she was repeatedly observed eating in the hallway outside her room, and staff were unaware of the care plan intervention. Facility leadership confirmed the care plan was not implemented as intended.
Staff failed to follow hand hygiene protocols during incontinence care for a resident with Alzheimer's Disease and severe cognitive impairment. Two CNAs did not remove gloves or perform hand hygiene before applying a clean brief and adjusting clothing, contrary to facility policy and infection control standards. The DON and Administrator confirmed the expected procedures were not followed.
A facility failed to ensure a resident rinsed her mouth after using a Symbicort inhaler, as observed during medication administration by an LPN. The resident, who was cognitively intact and had conditions including Type 2 Diabetes and wheezing, was not instructed to rinse, contrary to facility policy and manufacturer's guidelines. Interviews confirmed the oversight, with both the DON and NP emphasizing the importance of following guidelines to prevent complications.
A resident's CPAP mask was found uncovered and improperly stored, contrary to facility protocol requiring it to be sealed in a zip-lock bag to prevent contamination. The resident, who is cognitively intact and has a history of respiratory issues, reported that staff claimed they were not responsible for assisting with the mask. Interviews with an LPN and the DON confirmed the importance of proper storage to prevent infections.
A long-term care facility failed to maintain a medication error rate below 5%, with two errors observed. An LPN administered an incorrect dosage of Flonase nasal spray to a resident, while another LPN failed to instruct a resident to rinse their mouth after using a Symbicort inhaler. Both residents were cognitively intact, and the errors were acknowledged by the staff involved.
A facility failed to accurately code a resident's discharge on the MDS, indicating a discharge to an acute hospital instead of the resident's home with a Home Health Agency. The error was confirmed by the DON and an RN, who admitted to mistakenly coding the discharge due to workload and confusion. The facility's policy mandates adherence to RAI Guidelines for MDS accuracy.
A resident with Alzheimer's Disease and COPD refused Albuterol treatments for three consecutive days, but the facility failed to notify the physician and Resident Representative as required by policy. Interviews with staff revealed inconsistencies in following the notification procedure.
Failure to Obtain Physician Order for Oxygen
Penalty
Summary
The facility failed to obtain a physician order for oxygen before administering it to Resident #27, who was observed receiving oxygen at 2 ml while in bed eating lunch and again while in bed on a later observation. The facility’s Oxygen Guideline policy states that medical oxygen is classified by the FDA as a drug and is to be provided in accordance with a healthcare provider’s order and acceptable standards of practice. The DON stated the facility does not have standing orders and that the NP is called for all orders, and she confirmed oxygen is a medication that should not be given without a physician order. Record review showed Resident #27 was admitted with unspecified asthma, had a BIMS score of 14 indicating cognitive intactness, and the active order summary as of 1/6/26 did not include a physician order for oxygen.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Food was not stored and handled in accordance with professional standards for food safety during kitchen observations. A review of facility policy showed that all foods were to be stored labeled and dated, and hand hygiene was required after handling soiled equipment or utensils and after touching the face. During an initial kitchen tour, Refrigerator #2 contained a cup of thickened milk that the Dietary Manager identified as unlabeled and undated. The Dietary Manager acknowledged the milk had not been poured that morning and stated it should have been labeled and dated by the person who poured it so it could be used within a safe timeframe. During a second kitchen observation, staff were observed performing multiple unsanitary practices. A cook removed gloves, lifted the garbage can lid with bare hands, discarded the gloves, and then handled clean dishes from the dishrack and placed them on shelves and in drawers. The cook also touched cornbread with her hands while moving it from one pan to another for the food service line, touched her mouth, and then touched the thermometer used to check food temperature. A Dietary Aide used two water pitchers to fill glasses and then returned the used pitchers to the shelf with clean dishes. The cook, Dietary Aide, Dietary Manager, and Administrator all acknowledged the observed practices and stated the importance of sanitation and hand hygiene in the kitchen.
Incomplete Care Plans for PTSD and Oxygen Therapy
Penalty
Summary
The facility failed to develop a comprehensive care plan for PTSD for Resident #2 and failed to develop a care plan for oxygen therapy for Resident #27. The facility policy stated care plans would be developed for all residents based on RAI manual guidelines. Resident #2 was admitted with diagnoses including dementia with mood disturbance and chronic PTSD, and her MDS showed a BIMS score of 9 indicating moderate cognitive impairment. During interview, Resident #2 stated she had been in the Army for 34 years and had fought in a war that triggered her PTSD. Staff interviews confirmed that PTSD should be included in the care plan, with the DON stating the plan should contain details of PTSD so staff would know what to avoid and RN/MDS staff stating triggers should be included so staff would be aware while providing care. However, the comprehensive care plan did not include PTSD. Resident #27’s comprehensive care plan did not include oxygen usage. The resident was observed in bed eating lunch with oxygen flowing at 2 ml/hour, and an RN confirmed the resident was receiving oxygen at 2 ml/minute. The DON stated oxygen is a medication and should not be given without a physician order, and that the care plan should include oxygen so staff would know how to check saturation and tubing. RN/care plan staff stated that if oxygen was not on the physician orders, a care plan would not be developed, and that all staff use care plans to provide care. The record review showed Resident #27 had diagnoses including unspecified asthma, a BIMS score of 14 indicating cognitive intactness, and no physician order for oxygen on the active order summary.
Failure to Invite Resident to Activities
Penalty
Summary
The facility failed to provide activities and invitations to activities that met the psychosocial needs of one resident. Resident #19, who was admitted for rehab and had diagnoses including COPD, was cognitively intact with a BIMS score of 14. The resident’s Recreation Services Assessment listed activities he would enjoy, including Bingo, and during interview he stated he was new to the facility, was not interested in group activities, and would like one-on-one activities. He also stated he had not been offered any opportunities for activities since moving into the facility. During observations, the Activities Supervisor was seen walking from room to room inviting residents to scheduled activities, but passed Resident #19’s room without addressing the upcoming activities with him, including a morning activity and later Bingo. When interviewed, the resident confirmed he was not invited to any activity that day and stated he would have enjoyed playing Bingo. The Activities Supervisor acknowledged she did not invite the resident to activities tailored to his psychosocial needs, and the Administrator acknowledged that the resident had not received invitations to activities that were enjoyable to him.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to ensure infection control practices were followed during medication administration for one resident observed during a medication pass. During observation, an LPN entered the resident’s room and placed a nasal spray, inhaler, and lidocaine patch on the bedside table without disinfecting the surface or using a barrier. The LPN then administered the nasal spray, inhaler, and topical lidocaine patch without wearing gloves and without performing hand hygiene between the different medication routes. After administration, the LPN placed the used inhaler and nasal spray back into the unit’s general medication cart without disinfecting them first. The resident involved was cognitively intact with a BIMS score of 15 and had diagnoses including COPD. The resident’s MAR showed orders for azelastine-fluticasone nasal spray, lidocaine 4% patch, and Symbicort inhalation aerosol. During interview, the LPN stated she should have worn gloves for the topical patch and acknowledged she did not know gloves were required for nasal sprays or inhalers; she also stated she did not usually use a barrier when giving medications. The DON later confirmed the LPN should have performed hand hygiene and changed gloves between the inhaler, nasal spray, and transdermal patch, and that the bedside table should have been disinfected before medications were placed on it.
Failure to Update Care Plan for Resident Aggression
Penalty
Summary
The facility failed to revise the comprehensive care plan to reflect ongoing behavioral concerns and physical aggression for one resident. The resident was admitted with diagnoses including cerebral infarction, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. The resident’s MDS with an ARD of 10/7/25 showed a BIMS score of 13, and the MDS with an ARD of 10/24/25 coded physical behavioral symptoms directed toward others and verbal behavioral symptoms directed toward others. A review of the comprehensive care plan found no documentation of person-centered goals and interventions to address the resident’s repeated verbal and physical aggression toward staff. Facility staff reported multiple incidents of aggression involving the resident. CNA #1 stated the resident had physically abused her on multiple occasions, including hitting, kicking, and grabbing her, and said she reported the behavior to the NHA and was moved off the resident’s hall. CNA #2 stated she had witnessed the resident become aggressive with CNAs, CNA #3 stated the resident’s verbal and physical aggression was directed toward CNAs and confirmed being struck herself, and the roommate stated he had observed the resident hit CNAs. The RN stated she was aware of the behavior concerns but had not witnessed them herself and confirmed behavior concerns should be reflected in the care plan used by all staff to direct care. The Interim DON stated the Kardex used by CNAs is based on the comprehensive care plan and that behavior issues must be included in the care plan to guide all staff.
Incontinence Care and Catheter Maintenance Deficiencies
Penalty
Summary
The facility failed to provide incontinent supplies and services for three incontinent residents and failed to provide appropriate catheter care for a resident with an indwelling urinary catheter. Record review showed one resident had occasional urinary incontinence and frequent bowel incontinence, another was always incontinent of bowel and bladder, and a third was dependent on staff for toileting hygiene. Interviews with the Ombudsman, the residents, CNAs, and management described repeated times in October when staff reported there were no incontinence briefs available, certain sizes were unavailable, or care was delayed while staff waited for supplies to arrive or for a manager to unlock the supply room. One resident reported being told by staff on multiple occasions that the facility was out of briefs and that his care was postponed for at least an hour because no briefs were available. Another resident stated she had to wait for incontinence care after returning from therapy and reported prior occasions when she was told there were no briefs in her size. A third resident reported being told on a Sunday morning that she had to wait for care until staff could obtain briefs. CNA interviews confirmed shortages of incontinent supplies, delays in care, and that staff sometimes had to wait for management to bring a key to access the supply closet. The Administrator acknowledged that staff should have access to supplies and stated that a 55-minute wait was too long for requested incontinent care. The facility also failed to provide appropriate catheter care for a resident with an indwelling urinary catheter. On observation, the resident's room smelled strongly of urine, urine was on the floor under and beside the bed, and the catheter drainage bag and its blue cover were lying on the floor full to overflowing with urine. The resident stated that staff on the prior night shift and the day shift had not emptied the collection bag. The Administrator confirmed the room smelled like urine and that urine covered the floor area near the bed. A nurse stated she had not provided catheter care or checked to ensure it was provided, and the Corporate Nurse Consultant confirmed there was no physician's order for the indwelling catheter even though the resident's MDS identified an indwelling catheter.
Improper Linen Transport and Catheter Drainage Management
Penalty
Summary
Staff failed to handle and transport clean linens in accordance with accepted standards and failed to follow appropriate infection control practice for management of an indwelling catheter drainage system for one resident. Facility policy stated that soiled and clean linens must be covered during transportation and storage to prevent the spread of infection. During observation, a CNA carried a two-foot tall stack of clean linen down the hallway clutched to her body without a covering, and she stated she had forgotten her bag. She confirmed she knew linens should be covered during transport to carts and resident rooms to prevent the spread of infection. For a resident with diagnoses including benign prostatic hyperplasia, urinary tract infection, retention of urine, heart disease, and severe cognitive impairment, the resident's room smelled strongly of urine and the floor under and next to the bed was covered with urine dripping from a blue plastic urine bag cover. The resident stated that neither the prior night shift nor the day shift had emptied the urine collection bag, and the resident reported receiving treatment for a UTI during the stay. The ADON, who was also the facility IP, confirmed the urine collection bag and cover were overflowing, that urine had spilled onto the floor, and that nursing staff should monitor residents with indwelling catheters and empty collection bags as needed so they do not become full or overflowing.
Call Lights Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure residents could reasonably access their nurse call systems, as the call light was not within reach for two sampled residents. For one resident, the call light was attached to the right transfer bar of the bed and was not reachable from the wheelchair positioned on the left side of the bed; the resident stated he was not able to reach it. That resident’s MDS showed a BIMS score of 15, indicating cognitive intactness. For another resident, the call light was coiled and lying on the floor behind the head of the bed while the resident was resting in bed with the head of bed elevated and the bed against the wall facing the door. The resident confirmed he could not reach the call light. The resident’s MDS showed a BIMS score of 6, indicating severely impaired cognition. The Administrator, CNA, and LPN each observed or acknowledged that the call lights were out of reach and confirmed they had not noticed the issue.
Failure to Prevent Verbal, Mental, and Physical Abuse During Incontinence Care
Penalty
Summary
The facility failed to protect residents from verbal, mental, and physical abuse, as evidenced by the actions of a Certified Nurse Aide (CNA) toward two residents during incontinence care. One resident, who was cognitively intact and dependent for toileting hygiene, reported that the CNA struck his legs and scolded him after discovering his condom catheter had come off and his brief was wet. The resident experienced involuntary muscle spasms during care, and the CNA responded by hitting him and telling him to stop tensing up. The resident was left feeling afraid, humiliated, and unable to defend himself, resulting in emotional distress and a desire to leave the facility. Another resident, who had moderate cognitive impairment and was also dependent for toileting hygiene, reported that the same CNA scolded and berated him for being incontinent, making him feel ashamed, humiliated, and fearful that the behavior would recur. The CNA admitted to being frustrated and 'fussing' at the resident, telling him to stop urinating in bed after having to change his bed and clothes multiple times during the shift. The resident did not respond to the CNA but reported feeling intimidated and afraid. Interviews and record reviews confirmed that both residents experienced emotional distress as a result of the CNA's actions. Staff interviews corroborated the residents' accounts, with one staff member finding a resident crying and reporting the incident to nursing leadership. The facility's own policy prohibits abuse, including intimidation and the infliction of mental anguish, yet the CNA's conduct during care directly violated these standards, resulting in significant emotional harm to the residents involved.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
The facility failed to protect the dignity and privacy of three residents during care activities. For one resident with Alzheimer's Disease and severely impaired cognitive skills, two CNAs provided incontinence care with the window curtain open, exposing the resident's perineal area to the facility's front yard, porch, parking lot, and sidewalk. The staff did not notice the open curtain during the care. Another resident, who was cognitively intact and had a urinary tract infection, was observed with an uncovered catheter drainage bag containing clear yellow fluid, and the assigned CNA acknowledged awareness of the missing cover but was unaware of the reason for its necessity. Additionally, a third resident with senile degeneration of the brain was assisted with eating by a CNA who stood over the resident rather than sitting at the resident's side, as required for respectful feeding assistance. The CNA stated she stood because there was no chair available and was unaware of the expectation to be seated during meal assistance. The facility's policies and audit tools require privacy and dignity to be maintained during care, including closing window curtains and covering catheter bags, but these were not followed in the observed instances.
Failure to Investigate Allegation of Verbal and Mental Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of verbal and mental abuse reported by a resident with moderate cognitive impairment. The resident, who was always incontinent of bowel and bladder and required substantial assistance, reported that a CNA scolded him for wetting the bed, which made him feel ashamed and afraid. The incident was reported to the Assistant Director of Nursing Services (ADNS), who interviewed the resident and notified the Administrator. However, there was no evidence that a comprehensive investigation was conducted regarding this specific allegation. Interviews with facility staff revealed that the Social Services and Admissions Liaison was not instructed to assess or interview the resident, and the Director of Nursing Services was unaware of any follow-up or investigation into the allegation. The CNA involved admitted to scolding the resident but was not questioned about this specific incident during the investigation. The Administrator confirmed that no investigation, psychosocial assessment, or counseling was provided to the resident following the report of verbal and mental abuse.
Failure to Implement Care Plan Intervention for Fall Risk
Penalty
Summary
The facility failed to implement a comprehensive care plan intervention for one resident who was identified as being at risk for falls. According to the care plan, the resident was to be taken to the dining room for meals as a fall prevention measure. However, multiple observations showed the resident eating meals in her wheelchair in the hallway outside her room, rather than in the dining room as specified. Staff interviews confirmed that the resident typically ate all meals either in her room or in the hallway, and one CNA was unaware of the care plan intervention requiring dining room meals. The Director of Nursing Services and the Administrator both acknowledged the importance of care plan development and implementation, and confirmed that the intervention for dining room meals was intended to address fall risk. The resident involved had a diagnosis of Alzheimer's Disease and was assessed as having severely impaired cognitive skills for daily decision making. Despite the established care plan and facility policy, the intervention was not carried out as intended for this resident.
Failure to Follow Hand Hygiene Protocol During Incontinence Care
Penalty
Summary
The facility failed to follow proper hand hygiene practices during incontinence care for one of four sampled residents. During an observation, two CNAs provided incontinence care to a resident but did not remove their gloves or perform hand hygiene before applying a clean brief and adjusting the resident's clothing. The facility's Perineal Care Audit Tool specifies that staff should stop, remove gloves, wash or sanitize hands, and don clean gloves before proceeding with clean briefs and clothing. Interviews with the Director of Nursing Services and one of the CNAs confirmed that the expected procedure was not followed during the observed care. The resident involved had a diagnosis of Alzheimer's Disease and was noted to have severely impaired cognitive skills for daily decision making. The CNA involved acknowledged not changing gloves or performing hand hygiene during the care and understood the importance of proper technique. The Administrator confirmed that staff are expected to follow infection control standards as outlined in facility policy and training.
Failure to Instruct Mouth Rinsing After Inhaler Use
Penalty
Summary
The facility failed to ensure that a resident rinsed her mouth after the administration of a steroid Metered-Dose Inhaler, specifically Symbicort, which is necessary to prevent possible mouth and throat irritation. This deficiency was identified during an observation of medication administration by an LPN, who administered two puffs of the inhaler to the resident and exited the room without instructing her to rinse her mouth. The facility's policy and the manufacturer's guidelines both require rinsing the mouth after using Symbicort to reduce the risk of developing thrush, a fungal infection. The resident involved, who was admitted to the facility with diagnoses including Type 2 Diabetes with diabetic chronic kidney disease and wheezing, was found to be cognitively intact with a BIMS score of 15. During interviews, the LPN confirmed that she did not offer water for rinsing, and the resident stated she had never been asked to rinse her mouth after inhaler use. Both the DON and the NP confirmed the expectation for nurses to follow medication administration guidelines, including mouth rinsing to prevent complications.
Improper Storage of CPAP Mask Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to ensure proper storage of a CPAP mask for a resident, leading to a deficiency in infection control practices. During an observation, the resident's CPAP mask was found uncovered and lying on a dresser, contrary to the facility's protocol of storing the mask in a sealed zip-lock bag to prevent contamination. The resident reported that staff had informed him they were not responsible for assisting with the CPAP mask, indicating a lack of staff intervention in maintaining proper storage. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the CPAP mask should be stored in a bag to prevent respiratory infections. The Director of Nursing emphasized that it is the nursing staff's responsibility to ensure no breaches in infection control occur. The resident, who is cognitively intact, has a medical history that includes quadriplegia, chronic obstructive pulmonary disease with an acute lower respiratory infection, and obstructive sleep apnea, necessitating the use of a CPAP mask at bedtime.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by two medication errors observed out of 27 opportunities, resulting in a 7.4% error rate. The first error involved a Licensed Practical Nurse (LPN) administering Flonase nasal spray to a resident, where only one spray per nostril was given instead of the prescribed two sprays per nostril. The LPN admitted to not following the physician's orders and acknowledged the importance of administering the correct dosage for the medication to be effective. The resident involved was cognitively intact and had a diagnosis of Allergic Rhinitis. The second error occurred when another LPN administered two puffs of Symbicort inhaler to a resident without instructing them to rinse their mouth afterward, as required by the physician's orders to prevent thrush. The LPN confirmed the oversight and acknowledged the need to follow the guidelines for medication administration. The resident, who was also cognitively intact, had a history of Type 2 Diabetes with diabetic chronic kidney disease and wheezing. Interviews with the Director of Nursing and Nurse Practitioners confirmed the expectation for nurses to adhere to physician orders and medication administration guidelines.
Inaccurate Discharge Coding on MDS
Penalty
Summary
The facility failed to accurately code a discharge on the Discharge Minimum Data Set Assessment (MDS) for one of the sampled residents, leading to a deficiency in assessment accuracy. The resident in question was discharged to their home with a local Home Health Agency, but the Discharge MDS incorrectly indicated that the resident was discharged to an acute hospital. This error was confirmed during interviews with the Director of Nursing (DON) and a Registered Nurse (RN), who admitted to mistakenly coding the discharge due to being busy and possibly confusing the resident with another. The facility's policy requires that care plans and MDS be developed and maintained according to Resident Assessment Instrument (RAI) Guidelines, which was not adhered to in this instance.
Failure to Notify Physician and Resident Representative of Medication Refusal
Penalty
Summary
The facility failed to ensure the Physician and Resident Representative (RR) were notified when a resident refused to take medications. Specifically, Resident #3, who had diagnoses including Alzheimer's Disease and Chronic Obstructive Pulmonary Disease (COPD), refused Albuterol Sulfate HFA Aerosol Solution 108 mcg twice daily on three consecutive days. Despite the refusals being documented in the Electronic Medication Administration Record (EMAR), there was no documentation that the physician or the RR had been notified of these refusals as required by the facility's policy on Notifications of Patient/Resident Change. Interviews with various staff members, including the Director of Nurses (DON), Registered Nurses (RNs), and the Hospice Nurse, revealed inconsistencies in following the notification policy. The DON confirmed that nurses should document medication refusals and notify the provider. However, RN #1 and RN #2 could not recall if they had contacted the physician or the RR regarding Resident #3's refusals. The Hospice Nurse also indicated that she was not informed of the refusals, as there were no notes in the chart. The physician confirmed that he was not contacted about the refusals, which prevented him from developing an alternative treatment plan for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 36 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brookhaven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trend Health And Rehab Of Brookhaven | 0 mi | ★★★★★ | 6 | 0 |
| Silver Cross Health & Rehab | 0.2 mi | ★★★★★ | 11 | 0 |
| Haven Hall Health Care Center | 0.9 mi | ★★★★★ | 7 | 0 |
| Pine Crest Guest Home Inc | 19.6 mi | ★★★★★ | 0 | 0 |
| Lawrence Co Nursing Center | 21 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Diversicare Of Brookhaven.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.