Diversicare of Brookhaven

Inspectors wroteBased on observation, interviews, record reviews and facility policy the facility failed to obtain a physician order for oxygen (02) before administrating for one (1) of two (2) residents reviewed for oxygen. Resident #27Findings include:A record review of the facility's Oxygen Guideline policy with an update of 8/1/24, revealed medical oxygen is classified by the Food and Drug Administration as a drug and therefore it is provided in accordance with a healthcare provider's order and in accordance with acceptable standards of practice .On 01/05/2026 at11:32 AM, in an observation of Resident #27 in bed eating lunch. Resident #27 has O2 flowing at 2 milliliters (ml). On 01/07/2026 at 8:20 AM, an observation of Resident #27 in bed oxygen flowing at 2ml. On 01/08/26 at 12:18 PM, in an interview, the Director of Nursing (DON) stated they do not have standing orders. [...]

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to store food and maintain sanitary practices in accordance with professional standards for food safety related to foods not dated, staff touching the garbage can lid and then touching clean dishes, touching food that is ready to eat with hands, staff touching their face then touching the food thermometer, placing used water pitchers back on the shelf with clean dishes during two (2) of (2) kitchen observations.

Inspectors wroteBased on observation, interviews, record reviews and facility policy review the facility failed to develop a comprehensive care plan regarding Post Traumatic Stress Disorder (PTSD) and for the use of oxygen (O2) therapy for two (2) of 20 care plans reviewed. Resident #2 and Resident #27.

Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to provide activities and invitations to activities to meet the residents' psychosocial needs for one (1) of 17 residents sampled.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure infection control practices were followed during medication administration for one (1) of three (3) residents observed for medication pass (Resident #52).

Inspectors wroteBased on observation, interview, facility policy review, and record review, the facility failed to revise the comprehensive care plan to reflect ongoing behavioral concerns and physical aggression for one (1) of three (3) sampled residents (Resident #1). Findings Include:A policy review of the facility's Care Plan policy dated 10/21 revealed culturally component goals and interventions for mood, behaviors, history of trauma, cognitive concerns. should be added to the comprehensive care plan .On 11/24/25 at 11:29 AM, in a phone interview, Certified Nursing Assistant (CNA) #1 stated Resident #1 had been physically abusive toward her on multiple occasions, including hitting, kicking, and grabbing her. She reported the behavior to the Nursing Home Administrator and was moved off the resident's hall. [...]

Inspectors wroteBased on observation, record review, policy review and interviews, the facility failed to provide incontinent supplies and services for one (1) resident with indwelling urinary catheter (Resident #4) and for three (3) incontinent residents out of six (6) sampled incontinent residents, Residents #1, #2 and #3.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility staff failed to handle and transport linens in accordance with accepted standards in order to provide hygienically clean linens and prevent the spread of infection for one (1) of five (5) observations and failed to follow appropriate infection control practice for management of drainage system associated with indwelling catheter within accepted standards of practice for one (1) of six (6) sampled residents, Resident #4. Record review of Facility History revealed the facility was cited 6/04/25 at level D for F880 for infection control due to improper handling of clean linen, therefore the scope and severity was increased to E.

Inspectors wroteBased on observations, policy review, and interviews the facility failed to ensure the right of the residents to reside and receive services in the facility with reasonable accommodation of resident needs to achieve independent functioning, dignity and well-being that reflect the resident's needs, specifically to call system within reach for two (2) of six (6) sampled residents, Resident #1 and Resident #4.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to protect residents right to be free from verbal, mental, and physical abuse for two (2) of four (4) sampled residents (Resident #2 and Resident #3). Specifically, Certified Nurse Aide (CNA) #1 verbally and physically abused Resident #2 during incontinence care on 5/21/25 by striking the resident's legs, scolding him, and failing to provide care in a safe, supportive, and respectful manner, resulting in the resident experiencing fear, shame, emotional distress, and feelings of helplessness. Additionally, CNA #1 verbally and mentally abused Resident #3 on 5/21/25 by scolding and berating the resident for incontinence, causing the resident to feel humiliated, ashamed, and fearful that the behavior would recur. Findings Included: [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure care was provided in a manner that protected the dignity and privacy of residents for three (3) of four (4) sampled residents (Resident #1, Resident #2, and Resident #4). Specifically, the facility failed to maintain privacy during incontinence care for Resident #1 when staff provided care with the window curtain open, exposing the resident's perineal area; failed to provide a catheter bag cover for Resident #2 to maintain dignity; and failed to assist Resident #4 with meals in a respectful manner by standing over the resident while providing feeding assistance, rather than sitting at the resident's side. Findings Include: [...]

Inspectors wroteBased on policy review, record review and interviews the facility failed to conduct a thorough investigation of an allegation of verbal and mental abuse for one (1) of two (2) sampled residents that reported an allegation of abuse, Resident #3.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions for one (1) of four (4) sampled residents reviewed for care plan implementation, Resident #1.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to follow hand hygiene practices consistent with accepted standards of practice during incontinence care for one (1) of four (4) sampled residents reviewed for incontinence care, Resident #1.

Inspectors wroteBased on observation, staff and resident interviews, record review, facility policy review, and manufacturer's guidelines review, the facility failed to ensure a resident rinsed her mouth after the administration of a steroid Metered-Dose Inhaler to prevent possible mouth and throat irritation for one (1) of one (1) resident observed for administration of a Metered-Dose Inhaler. (Resident #32)

Inspectors wroteBased on observation, staff and resident interviews and record review the facility failed to ensure that a resident's CPAP (Continuous Positive Airway Pressure) mask was properly stored when not in use, for one (1) of fourteen (14) sampled residents. (Resident # 48) Findings Include: During an observation and interview with Resident #48 on 06/17/24 at 11:10 AM, he stated that he had been told by staff that they were not responsible for assisting with his CPAP mask. The resident's CPAP mask was observed uncovered and lying on the dresser near the foot of the resident's bed. On 06/17/24 at 4:28 PM, during an observation and interview, License Practical Nurse (LPN) #3 stated that the CPAP mask should be in a bag. She explained that this is to prevent the resident from contracting respiratory infections. [...]

Inspectors wroteBased on observations, resident and staff interviews and record reviews, the facility failed to ensure a medication error rate of less than 5%, as evidenced by two (2) medication errors observed out of 27 opportunities for errors, resulting in a medication error rate of 7.4%. Residents #25 and #32 Findings Include: Review of the facility's policy for Medication Administration, titled, , Administration of Nasal Spray Preparations, dated 04/22 revealed, Medications are administered as prescribed . Personnel authorized to administer medication do so only after they have familiarized themselves with the medications . Review of the facility's policy for Medication Administration, titled, Administration of Metered dose Inhalers, reviewed/updated 04/22, revealed, Medications are administered as prescribed . [...]

Inspectors wroteBased on record reviews, staff interviews, and facility policy review, the facility failed to correctly code a discharge from the facility on the Discharge Minimum Data Set Assessment (MDS) for one (1) of 14 sampled residents reviewed for assessment accuracy. Resident #49 Findings Include: Record review of the facility's policy titled, MDS and Care Plans, with the latest effective date, August 2019, revealed, Care plans and MDS will be developed and maintained per RAI (Resident Assessment Instrument) Guidelines. Record review of the facility's, Progress Notes, revealed Resident #49 was discharged to home, with a local Home Health Agency on 4/2/2024. Record Review of the Discharge MDS, with an Assessment Reference Date (ARD) of 04/02/24, revealed in Section A that Resident #49 was discharged to an acute hospital. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure the Physician and Resident Representative (RR) were notified when a resident refused to take medications for one (1) of seven (7) sampled residents. (Resident #3)

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to ensure cookware was properly sanitized for one (1) of two (2) kitchen tours. All 55 residents residing in the facility had the potential to be affected. Findings Include: A review of the Facility's policy, Manual Warewashing Policy, revised 09/2017, revealed, . All cookware, dishware, and serviceware that is not processed through the dish machine will be manually washed and sanitized. Procedures 1. The Dining Service staff will be knowledgeable in proper technique including .chemical sanitizer testing and concentrations. 2. Appropriate test strips will be utilized to measure the concentration of the sanitizer solution. Results will be recorded on the Three-Compartment Sink Log . [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review the facility failed to maintain a properly functioning call system for one (1) of four (4) halls observed. B Hall Findings Include: Review of facility's policy titled, Nurse Call System, dated September 1, 2014, revealed Purpose: To maintain center call systems in an ideal mechanical condition to ensure optimum performance when residents request assistance from staff. Monthly the Nurse call system should be checked for the following: 4. Any component that does not function should be repaired as soon as practically feasible. 5. Systems with audio functions should be tested monthly. Any non-operating components should be repaired as soon as practically feasible. [...]

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to honor a resident's right to choose health care by not administering the requested influenza vaccination to a resident upon admission for one (1) out of 6 (six) vaccination records reviewed.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure a PASRR (Pre-admission Screening and Resident Review) Level II was obtained for a resident after a diagnosis of a serious mental disorder was received for one (1) of five (5) resident records reviewed. Resident #20.

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, the facility failed to store the Flonase belonging to Resident #109 in a locked compartment to prevent possible overdose of a medication for one (1) of five (5) medication observations. Resident #109 Findings Include: Record review of the facility's, Medication Administration Competency Checklist, reveals the facility uses [NAME] and [NAME], Clinical Nursing Skills & Techniques, 8th Edition, as their medication administration policy and procedure. Review of the checklist revealed . 2. Administered medications: p. Stayed with the resident until the resident completely took all medication by the prescribed route, . Review of the facility's, Licensed Nurse Core Clinical Competency, revealed RN #1 was checked off on Medication Administration on 10/29/22. [...]