Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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.
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 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.
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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) |
|---|---|---|---|---|
| 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 | — | 0 | 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 August 2026) and official state health department websites.