Diversicare Of Brookhaven

F 0558

Reasonably accommodate the needs and preferences of each resident.

Level of Harm - Minimal harm or potential for actual harm

Based 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. Findings included: Policy

review of the facility policy titled, Nurse Call System Effective Date 9/01/14, revealed the policy revealed, 2.

Each cord needs to be visible and reachable by the resident to which it operates for . Resident #1On 10/20/25 at 1:25 PM during observation and interview with Resident #1 in his room revealed the call light for Resident #1 was attached to the transfer bar on the right side of the resident's bed by a clamp and not within the reach of the resident seated in his wheelchair on the left side of the bed. Resident #1 stated that

he was not able to reach the call light.Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/14/25 revealed a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. Resident #4On 10/21/25 at 12:25 PM observation and

interview with Resident #4 revealed the resident was resting in his bed, which was against the wall facing

the door with head of bed elevated and his call light was coiled and lying on the floor behind the head of the resident's bed. Resident #4 confirmed that he was not able to reach his call light. Record review of Resident #1's MDS with an ARD of 9/19/25 revealed a BIMS score of 6, indicating severely impaired cognition.On 10/21/25 at 12:40 PM observation and interview with the Administrator in the rooms of Resident #1 and Resident #4 revealed that she confirmed that Resident #1's call light was not within his reach as he was seated in his wheelchair on the left side of the bed and the call light was attached to his bed's right transfer bar. The Administrator confirmed that Resident #4 could not reach his call light coiled and lying on the floor behind the head of his bed.On 10/21/25 at 1:03 PM during an interview, Certified Nursing Assistant (CNA) #5 stated that she was assigned to the care of Resident #1 and Resident #4. She stated that she had not touched the call light of Resident #1 all day and confirmed that the call light was not in reach of the resident as he was seated in his wheelchair on the left side of the bed and the call light was attached to his bed's right transfer bar. She confirmed that making sure each resident's call light was within their reach was important to ensure the residents could call for assistance as needed. She said that Resident #4 could not reach his call light coiled up and lying on the floor behind the head of his bed. She said she had not noticed that the resident's call light had been out of their reach. On 10/21/25 at 1:30 PM an interview with Licensed Practical Nurse (LPN) #1 revealed she stated that she had been in the rooms of Resident #1 and Resident #4 and had not noticed that their call lights were out of reach. She confirmed it was important for residents to have their call bells in reach to summon assistance as needed.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Brookhaven

519 Brookman Drive Brookhaven, MS 39601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

for assistance with personal care, and cerebral infarction. Record review of the Nursing Home Part A PPS Discharge MDS with ARD 9/22/25 for resident #3 revealed the resident had a BIMS score of 6, which indicated severe cognitive impairment. The MDS review revealed the facility assessed the resident as dependent on staff for toileting hygiene and walking 10 feet with toilet transfer not attempted due to medical condition or safety concerns with continuous oxygen therapy. Resident #4On 10/21/25 at 12:25 PM

observation and interview with Resident #4 revealed the resident's room smelled strongly of urine and there was a six (6) square foot area of the floor under and next to the resident's bed that was covered in urine which was dripping from a blue plastic urine bag cover. The resident said that the prior night shift nor the 10/21/25 day shift staff had emptied his urine collection bag. On 10/21/25 at 12:39 PM interview in the room of Resident revealed the Maintenance Supervisor stated that the room smelled like urine. On 10/21/25 at 12:40 PM observation and interview with the Administrator in Resident #4's room revealed she confirmed that Resident #4's room smelled like urine and that there was approximately seven (7) square feet of the floor beneath and beside the resident's bed that was covered with urine. On 10/21/25 at 12:45 PM

observation revealed the uncovered catheter urine collection bag was lying on the floor next to the Resident #4's bed along with the blue plastic urine collection bag cover, both were full to overflowing with urine.

There was urine covering an eight square foot area of the floor beneath and next to the resident's bed, which was against the wall. The ADON and Wound Care Nurse emptied the urine collection bag into two (2) urinals and attempted to empty the blue plastic cover into a urinal and spilled an undeterminable amount onto the floor. Due to spillage the total amount of urine in the collection bag and the cover was not able to be determined. SA observed three (3) standard plastic 1000 milliliter (ml) urinals were filled from the collection bag and cover. On 10/21/25 at 1:03 PM CNA #5 stated that she had not noticed that resident #4's urine collection bag was full or overflowing or that there was urine under and beside his bed when she was

in his room prior to 12:30 PM on 10/21/25. She confirmed that she had been in Resident #4's room and removed his lunch tray and clocked out for lunch; she stated that she did not smell urine in Resident #4's room because, I can't really smell. On 10/21/25 at 1:30 PM an interview with LPN #1 revealed she stated that she had not provided catheter care or checked to ensure catheter care was provided for Resident #4

on 10/21/25. She stated that the nurses were responsible for supervision of resident care. She stated that

she had glanced at the indwelling catheter urine collection bag in it's blue cover and had not noted anything unusual or any problem with the drainage collection system between 12:00 PM and 12:30 PM. She stated that on 10/19/25 the HRC had reported to the facility and the storage room where incontinent briefs were stored and opened the room with a key at approximately 9:30 AM. On 10/21/25 at 3:25 PM during interview

the Corporate Nurse Consultant confirmed that there was no physician's order for indwelling catheter for Resident #4 and that if a resident had an indwelling catheter, they should have a corresponding order.

Record review of the admission Record for Resident #4 revealed the facility admitted the resident on 9/12/25 and the resident had diagnoses of benign prostatic hyperplasia, need for assistance with personal care, urinary tract infection, and retention of urine.Record review of the admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 9/19/25 revealed the resident had a BIMS score of 6, which indicated severe cognitive impairment. The MDS review revealed the facility assessed the resident as having an indwelling catheter.Record review of the order Summary Report for Resident #4 revealed no physician's order for indwelling catheter.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Brookhaven

519 Brookman Drive Brookhaven, MS 39601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

become full or overflowing.On 10/21/25 at 2:00 PM an interview with the Administrator revealed she expected nurses and the ADON and DON to supervise the CNAs and care of residents, and that she expected the CNA.s to transport clean linens covered with disposable trash can liners supplied by the facility. The Administrator confirmed that she expected nursing staff to monitor residents with indwelling catheters and associated urine collection systems and meet the needs of those residents, including emptying the collection bags as needed.Record review of the admission Record for Resident #4 revealed

the facility admitted the resident on 9/12/25 and the resident had diagnoses of benign prostatic hyperplasia, need for assistance with personal care, urinary tract infection, retention of urine, and heart disease.Record

review of the admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 9/19/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. The MDS review revealed the facility assessed the resident as having an indwelling catheter.

Event ID:

Facility ID:

If continuation sheet