Diversicare of Brookhaven: Care Plan Failures - MS
The certified nursing assistant told federal inspectors she had been physically abused by the resident "on multiple occasions, including hitting, kicking, and grabbing her." She reported the attacks to the nursing home administrator and was eventually moved off the resident's hall.
But the facility's comprehensive care plan contained no documentation of goals or interventions to address the resident's repeated verbal and physical aggression toward staff, inspectors found during a November 24 complaint investigation.
The resident had been admitted September 30 with diagnoses including cerebral infarction, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. Within two weeks, the attacks began.
Progress notes documented a pattern of escalating violence. On October 12, the resident showed "combative behavior toward CNA." Six days later, the resident "slapped a CNA in the face and kicked her in the chest."
The attacks intensified. On October 20, the resident "slapped a CNA in the face and pulled her hair down and punched her in the face." The same day as the face-slapping incident, the resident "hit a nurse in the abdomen."
The violence continued into November. On November 2, the resident "punched a CNA with a closed fist."
Multiple staff members witnessed or experienced the aggression. A second nursing assistant told inspectors she had seen the resident become aggressive with CNAs. The resident's roommate confirmed he had observed the resident hit nursing assistants.
A third nursing assistant stated that the resident's verbal and physical aggression was directed toward CNAs and confirmed being struck herself.
The registered nurse on duty said she was aware of the behavior concerns but had not witnessed them herself. She told inspectors that behavior concerns should be reflected in the care plan, which is used by all staff to direct care.
Another nursing assistant explained she uses the care plan to guide her care provision. The interim director of nursing confirmed that the Kardex used by CNAs is based on the comprehensive care plan. She stated behavior issues must be included in the care plan to guide all staff.
Despite this understanding among nursing leadership, the resident's care plan remained unchanged.
The resident's cognitive assessment showed a Brief Interview for Mental Status score of 13, indicating cognitive intactness. A subsequent assessment on October 24 coded for both physical behavioral symptoms directed toward others and verbal behavioral symptoms directed toward others.
When inspectors observed the resident on November 24 at 12:18 PM, the resident was calm in bed, oriented to two domains, and intermittently providing appropriate responses.
But the documented pattern of violence against staff continued without any formal intervention strategy. The facility's own care plan policy, dated October 21, required culturally component goals and interventions for mood, behaviors, history of trauma, and cognitive concerns to be added to comprehensive care plans.
The nursing assistant who was moved off the resident's hall had reported the physical abuse to administrators. Yet no systematic approach was developed to protect other staff members who continued providing care.
The failure to update the care plan left nursing assistants without guidance on how to safely interact with a resident who had demonstrated a clear pattern of striking, kicking, and grabbing caregivers. The omission also meant incoming staff had no warning about the documented behavioral concerns.
Federal regulations require facilities to develop complete care plans within seven days of comprehensive assessments, prepared and reviewed by a team of health professionals. The care plan must be revised to reflect ongoing concerns.
At Diversicare of Brookhaven, staff continued working with a resident who had punched them with closed fists while managers failed to document any strategy for preventing future attacks.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Diversicare of Brookhaven from 2025-11-24 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 20, 2026 · Our methodology
DIVERSICARE OF BROOKHAVEN in BROOKHAVEN, MS was cited for violations during a health inspection on November 24, 2025.
Within two weeks, the attacks began.
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.