Diversicare of Brookhaven: Infection Control Gaps - MS
The October inspection revealed the resident's urine collection bag had overflowed so completely that three standard 1,000-milliliter urinals were needed to contain what spilled across the floor beneath and beside his bed.
When inspectors arrived at the facility on October 21 at 12:25 PM, Resident #4's room reeked of urine. The catheter bag and its blue plastic cover both sat on the floor, full to overflowing. Urine had pooled in a spreading lake under his bed, which was pushed against the wall.
The resident told inspectors that neither the night shift staff nor the day shift workers had emptied his urine collection bag.
The facility's maintenance supervisor confirmed the overpowering smell when interviewed in the room at 12:39 PM. One minute later, the administrator walked into the same room and acknowledged both the stench and the seven square feet of urine she could see covering the floor.
By 12:45 PM, when inspectors returned for a more detailed observation, the urine had spread to eight square feet.
The assistant director of nursing and wound care nurse finally arrived to empty the collection system. They filled two urinals from the catheter bag alone, then tried to empty the blue plastic cover into a third urinal. More urine spilled onto the floor during this process, making it impossible to measure exactly how much had accumulated.
The resident had been admitted to the facility on September 12 with diagnoses including benign prostatic hyperplasia, urinary tract infection, and urine retention. His admission assessment showed severe cognitive impairment, with a score of 6 on the cognitive assessment scale. The facility documented that he required an indwelling catheter.
But when inspectors reviewed his medical orders, they found no physician's order for the catheter he was wearing.
The Corporate Nurse Consultant confirmed during a 3:25 PM interview that residents with indwelling catheters should have corresponding physician orders. None existed for Resident #4.
Staff members offered conflicting explanations for the failure.
CNA #5 said she had been in the resident's room before 12:30 PM to remove his lunch tray before clocking out for lunch. She claimed she hadn't noticed the full catheter bag or the urine covering the floor. When pressed about the overwhelming smell, she said, "I can't really smell."
LPN #1 acknowledged she was responsible for supervising resident care but admitted she hadn't provided catheter care or checked to ensure someone else had done so on October 21. She said she had glanced at the catheter bag in its blue cover between noon and 12:30 PM but "had not noted anything unusual or any problem with the drainage collection system."
The inspection occurred after complaints prompted federal investigators to visit the facility. During their review, they also examined records for other residents with similar care needs.
Resident #3, who was discharged in September, had the same severe level of cognitive impairment as Resident #4. That resident's assessment showed complete dependence on staff for toileting hygiene and an inability to walk even 10 feet due to medical conditions and safety concerns. The resident required continuous oxygen therapy.
The facility's failure extended beyond basic catheter maintenance. Federal regulations require nursing homes to ensure residents receive proper treatment and care for urinary incontinence and catheter care when medically necessary. The regulations also mandate that facilities follow physician orders for all treatments and interventions.
The scene inspectors documented suggests a breakdown in multiple layers of care. Night shift staff left the catheter bag unemptied. Day shift workers ignored the accumulating urine through an entire morning. The licensed practical nurse responsible for supervision failed to notice a problem that had created an eight-square-foot pool of urine.
Most significantly, the resident was receiving catheter care without any physician's order authorizing the medical device.
The resident's severe cognitive impairment, documented through standardized assessment tools, meant he was entirely dependent on staff to recognize and address the unsanitary conditions surrounding him. His cognitive score of 6 indicated he lacked the mental capacity to advocate for himself or communicate effectively about his care needs.
The overflowing catheter represented more than poor housekeeping. Urine-soaked floors create infection risks, fall hazards, and skin breakdown dangers for residents who spend most of their time in bed or using mobility aids in their rooms.
The facility's corporate structure includes oversight from nurse consultants who confirmed basic care standards weren't being met. Yet the breakdown occurred despite multiple staff members entering the resident's room throughout the morning shift.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to some residents. The finding suggests similar catheter care failures could be affecting other residents with cognitive impairments who cannot report problems or advocate for proper care.
The inspection report does not indicate whether Resident #4 developed infections, skin breakdown, or other medical complications from sitting in the urine-contaminated environment. It also doesn't specify how long the catheter bag had been overflowing before inspectors arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Diversicare of Brookhaven from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
DIVERSICARE OF BROOKHAVEN in BROOKHAVEN, MS was cited for violations during a health inspection on November 18, 2025.
When inspectors arrived at the facility on October 21 at 12:25 PM, Resident #4's room reeked of urine.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.