Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Trend Health And Rehab Of Brookhaven during CMS and state inspections, most recent first.
A resident with paroxysmal atrial fibrillation and intact cognition was transferred using a mechanical lift by a single CNA, contrary to facility policy requiring two staff for all mechanical lift transfers. During the transfer, the lift pad shifted and the resident slipped from the sling, falling to the floor and sustaining a broken fingernail. The CNA reported she was alone because other staff were unavailable and described a facility change in strap placement method that had been in effect at the time. The DON confirmed that the incident involved a solo mechanical lift transfer, that policy requires two staff with one acting as a spotter, and that the CNA had not received follow-up lift training since hire.
A resident with a BIMS of 15 and a care plan for 2-person Hoyer lift transfers was moved by only one CNA using a mechanical lift. During the transfer, the lift pad shifted, the resident slipped out, and fell to the floor. The resident, CNA, DON, and MDS/Care Plan LPN all confirmed the resident was supposed to have 2 staff assist with lift transfers, but only one staff member was present.
Medication error rate exceeded the threshold when an LPN could not locate ordered meds for two residents during med prep. One resident’s Flonase nasal spray was unavailable despite an active daily allergy order, and another resident’s Famotidine was unavailable despite an active BID GERD order. The DON stated nurses are expected to reorder meds when five doses remain and that meds should never be depleted.
Emergency Medication Kit Left Unlocked: The facility failed to keep the emergency medication kit secured. During observation, the kit was found missing its zip lock tie and left unlocked with numerous medications inside. An LPN, RN/Charge Nurse, and DON all confirmed the kit should always be locked, and the facility policy stated emergency medications are removed by breaking the seal and then securing the kit again. Record review also showed multiple Emergency Box Requisitions where nurses removed medications but left the replacement lock section blank.
Food items in the kitchen refrigerator were found undated and not labeled in accordance with the facility's food storage policy. Two wrapped containers, one with oatmeal and one with pureed eggs, were observed without dates, and the dietary aide stated she had been in a hurry and planned to date them later. The Dietary Manager confirmed food must be labeled and dated so staff can determine when it was prepared and noted the items were not dated as required.
Hand hygiene was not performed as required during care for three residents. An LPN failed to clean hands before and between glove changes during PEG site care for one resident, another LPN touched multiple environmental surfaces during enteral feeding care without removing gloves or performing hand hygiene, and a third LPN donned gloves without hand hygiene before applying a Lidocaine patch. The facility policy stated gloves do not replace hand hygiene.
The facility failed to follow infection control practices for two residents on Enhanced Barrier Precautions (EBP). An LPN did not perform hand hygiene before providing PEG tube care, and a CNA did not wear the required gown during peri care. Both residents had active orders for EBP due to their medical conditions, and staff acknowledged the lapses in infection control procedures.
A resident's room was found to have a strong smell of urine and mildew, flies, missing paint, and a soiled privacy curtain, compromising the homelike environment. The resident, with moderate cognitive impairment and an Overactive Bladder diagnosis, expressed concerns about these conditions, which were confirmed by facility staff.
The facility failed to implement care plan interventions for two residents on Enhanced Barrier Precautions due to PEG tubes. An LPN did not perform hand hygiene before providing PEG tube care, and a CNA did not wear the required gown during perineal care. Both staff members acknowledged their actions posed infection control risks. The Director of Nursing confirmed that the care plans required hand washing and PPE use, which were not followed.
A resident with Hyperlipidemia and Type 2 Diabetes did not receive a physician-ordered daily side salad with ranch dressing at lunch. Despite the order being communicated to the Dietary Department, the Dietary Manager was unaware and had stopped purchasing salads due to cost concerns. The resident and her sister expressed dissatisfaction, and the issue was confirmed through observations and interviews.
Failure to Follow Two-Person Mechanical Lift Policy Resulting in Resident Fall
Penalty
Summary
The facility failed to ensure safe transfer practices by not following its policy requiring two staff members for all mechanical lift transfers. Facility policy dated 3/16 stated that use of a mechanical lift requires two nursing assistants or nurses each time it is used. Record review of a Facility Reported Incident showed that on 01/07/2026, a CNA used a mechanical lift alone to transfer Resident #30. During this transfer, the lift pad moved and the resident slipped from the lift, falling to the floor. No malfunctions were identified with the lift or lift pad. Resident #30, who had a diagnosis including paroxysmal atrial fibrillation and a BIMS score of 15 indicating intact cognition, confirmed in interview that only one CNA was present and that she was lifted high in the air when the lift strap slipped, causing her to fall straight to the ground. She reported no bruising or fractures but did sustain a broken fingernail. In a subsequent interview, CNA #1 confirmed she was alone in the room during the mechanical lift transfer when the resident began to slip and slid out of the lift pad, falling to the floor. She stated that the facility had changed the lifting method, directing staff to place lift pad straps underneath the legs instead of between the legs, and that she had attended an in-service within the last year related to this change. She also stated she was alone because other staff were unavailable at the time. The DON confirmed that an investigation found CNA #1 transferred the resident alone using a mechanical lift and reiterated that facility policy requires two staff members during mechanical lift use so that one staff member can act as a spotter if the lift begins to slip or fall. The DON also stated that CNA #1 had not completed follow-up lift training since her hire date in 2021 due to working on an as-needed basis, while confirming that staff are expected to follow the lifting policy at all times.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan
Penalty
Summary
The facility failed to ensure staff followed the resident's comprehensive care plan and mechanical lift policy for safe transfers. The facility policy stated that each resident's comprehensive care plan must include measurable objectives and timeframes to meet identified needs, and the resident's care plan initiated 2/7/25 directed staff to use a Hoyer lift with 2 staff assistance for transfers to chair or bed. Resident #30 was admitted with diagnoses including paroxysmal atrial fibrillation, and the MDS dated with ARD 11/11/2025 showed a BIMS score of 15, indicating the resident was cognitively intact. The reportable incident investigation found CNA #1 transferred Resident #30 alone using a mechanical lift on 1/07/2026. During the transfer, the lift pad moved and the resident slipped out of the lift and fell onto the floor. The resident confirmed only one CNA was present and stated she was lifted high in the air when the strap slipped, causing her to fall straight to the ground. CNA #1 confirmed she was alone during the transfer and that the resident slid out of the lift pad and fell. The DON and the MDS/Care Plan LPN both confirmed the care plan required two staff members for mechanical lift transfers and that staff were expected to follow both the care plan and facility lift policy.
Medication Not Available for Ordered Administration
Penalty
Summary
The facility failed to ensure medications were available for administration as ordered, resulting in a medication error rate of 6.9% based on 2 of 29 medication administration opportunities. During observation, LPN #4 was preparing medications for Resident #3 when Flonase 0.05 mg/actuation nasal spray was not available, and the nurse searched the medication room but could not locate it. Resident #3 was admitted with a diagnosis of allergy, unspecified, subsequent encounter, and had an order for Flonase Allergy Relief Nasal Suspension, fluticasone propionate nasal, two sprays in both nostrils daily for allergies. The resident’s MDS showed a BIMS score of 14, indicating the resident was cognitively intact. During another observation, LPN #4 was preparing medications for Resident #62 when Famotidine 10 mg oral tablet was not available, and the nurse searched the medication room but could not locate it. Resident #62 was admitted with a diagnosis of gastroesophageal reflux disease without esophagitis and had an order for Famotidine 10 mg by mouth every morning and at bedtime. The resident’s MDS showed a BIMS score of 15, indicating the resident was cognitively intact. The DON stated nurses are expected to reorder medications when the supply reaches five doses remaining in a blister pack, that over-the-counter medications are ordered weekly, and that medications should never be depleted.
Emergency Medication Kit Left Unlocked
Penalty
Summary
The facility failed to ensure the emergency medication kit was secured and locked to prevent unauthorized access and to ensure availability of medications for emergency use. During observation of the medication storage room, the Emergency kit was found missing a zip lock tie and contained numerous medications in an unlocked condition. An LPN confirmed the kit was not locked and stated it was supposed to be locked at all times because it contains medications for emergency usage only. The LPN also stated the lock is intended to prevent anyone from removing medications without signing them out and to ensure the medications remain available when needed for emergencies. An RN/Charge Nurse later confirmed the kit was not locked and stated it should have a zip tag on it and should always be locked. She stated nurses are responsible for placing a lock on the kit after opening it and can contact pharmacy for more locks. The DON also confirmed the kit should be locked and stated the last nurse who removed medication should ensure it is locked. Record review showed the facility’s policy stated that when emergency or starter dose medications are needed, the nurse breaks the container seal and removes the required medication. The Emergency Box Requisitions form showed three nurses removed medications from the kit but left the replacement lock section blank on multiple dates.
Undated Food Items in Kitchen Refrigerator
Penalty
Summary
Food items were not properly dated and labeled in the kitchen refrigerator in accordance with the facility's food storage policy. The policy required all foods to be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross contamination. During observation, two wrapped containers on the bottom shelf of the refrigerator, one containing oatmeal and the other containing pureed eggs, were found undated. In interview, the dietary aide stated the items should have been dated so staff would know if the food was fresh and said she had been in a hurry to get trays out and planned to date them later. The Dietary Manager confirmed that food items are required to be labeled and dated so staff can determine when the food was prepared and stated regulations require food to be discarded after seven days; he also confirmed staff did not follow regulations by failing to date the items.
Hand Hygiene Not Performed During Resident Care
Penalty
Summary
The facility failed to ensure staff performed hand hygiene in accordance with infection prevention standards before donning gloves, after glove removal, and after contact with contaminated surfaces during care for three residents. The facility policy on Hand Hygiene stated that gloves do not replace hand hygiene and that hand hygiene should be performed prior to donning gloves and immediately after removing gloves. During observation of PEG tube site care for Resident #3, an LPN removed a soiled dressing and did not perform hand hygiene before putting on new gloves, then repeated glove changes without hand hygiene between steps while cleansing the PEG site and applying a new dressing. Resident #3 had been admitted with sequelae of cerebral infarction and had a BIMS score of 14, indicating cognitive intactness. During observation of bolus enteral feeding for Resident #56, an LPN donned gloves, touched the bed remote control, opened the bathroom door, and turned the water faucet on and off without performing hand hygiene upon entry or removing gloves before touching environmental surfaces and proceeding with the feeding. Resident #56 had been admitted with diagnoses that included the observed feeding care. During observation of topical medication application for Resident #62, an LPN donned gloves upon entering the room but did not perform hand hygiene before glove application or before applying a Lidocaine patch to the resident's lower back. Resident #62 had been admitted with a diagnosis including wedge compression fracture of the lumbar vertebra and had a BIMS score of 15, indicating cognitive intactness.
Infection Control Lapses in EBP Care
Penalty
Summary
The facility failed to ensure proper infection control practices during care for residents on Enhanced Barrier Precautions (EBP). During an observation, an LPN did not perform hand hygiene before applying gloves while providing PEG tube care to a resident. The LPN also failed to perform hand hygiene after handling contaminated supplies that fell on the floor. The resident had active orders for PEG tube care due to a gastrostomy infection and was on EBP. The resident's cognitive skills were severely impaired, and they had a feeding tube. In another instance, a CNA provided peri care to a resident without wearing the required gown, which is part of the EBP. The CNA acknowledged the failure to wear proper PPE, which could lead to the transmission of germs. The resident had active orders for EBP related to their PEG tube. Interviews with the DON and the Infection Preventionist confirmed the importance of hand hygiene and wearing appropriate PPE to prevent cross-contamination and infection transmission.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to ensure a resident's right to a clean, comfortable, and homelike environment, as evidenced by several deficiencies in the living conditions of a resident's room. Observations revealed a strong smell of urine and mildew, the presence of flies, missing paint on the walls, and a soiled privacy curtain with visible food and other stains. These conditions were noted during multiple observations and were confirmed by both the Facility Administrator and Housekeeping Staff. The resident involved, who was admitted with a diagnosis of Overactive Bladder, expressed significant concerns about the living conditions, stating that the persistent odor led her to spend most of her time outside her room. The resident's cognitive status was moderately impaired, as indicated by a BIMS score of 9. Despite the facility's policy to maintain a safe and homelike environment, the cleanliness and maintenance of the resident's room were not upheld according to the facility's standards.
Failure to Implement Care Plan Interventions for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement care plan interventions for two residents who were on Enhanced Barrier Precautions due to having PEG tubes. For Resident #24, a Licensed Practical Nurse (LPN) did not perform hand hygiene before applying gloves and providing PEG tube care. This occurred both when initially entering the room and after re-entering the room during the procedure. The LPN admitted to forgetting to wash her hands, acknowledging the infection control risks posed by her actions. For Resident #40, a Certified Nursing Assistant (CNA) was observed providing perineal care without wearing the required gown as part of the PPE for residents on Enhanced Barrier Precautions. The CNA confirmed not wearing the gown and admitted that this could spread germs to the resident. The Director of Nursing and the care plan nurse confirmed that the comprehensive care plans for both residents required hand washing and the use of PPE, including gowns and gloves, during high-contact care activities, which were not followed by the staff.
Failure to Provide Physician-Ordered Diet
Penalty
Summary
The facility failed to provide a resident with a physician-ordered salad during lunch meals, as observed in the case of one resident. The resident, who was admitted with diagnoses including Hyperlipidemia and Type 2 Diabetes, had a physician's order for a daily side salad with ranch dressing on her lunch tray. Despite this order, the resident reported not receiving salads for several months and expressed her dissatisfaction with the kitchen's failure to meet her food preferences. The resident's sister also voiced frustration over the facility's inability to honor the resident's dietary requests. The Dietary Manager admitted to not updating the resident's food preferences and had stopped purchasing salads due to cost concerns. She was unaware of the physician's order for the salad, despite the Director of Nursing confirming that the Dietary Department had been notified. The Registered Dietician also stated that she communicated dietary assessments and recommendations to the relevant staff, including the Dietary Manager. The failure to provide the ordered salad was documented through observations and interviews, highlighting a breakdown in communication and adherence to dietary orders within the facility.
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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.
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Nursing homes near Brookhaven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diversicare Of Brookhaven | 0 mi | ★★★★★ | 9 | 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 |
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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.