Diversicare Of Brookhaven

Based 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.On 11/24/25 at 12:18 PM, Resident #1 was observed calm in bed, oriented to two domains, intermittently providing appropriate responses.On 11/24/25 at 12:30 PM, CNA #2 stated she had witnessed Resident #1 become aggressive with CNAs.On 11/24/25 at 12:53 PM, Resident #3, the roommate of Resident #1, stated he had observed Resident #1 hit CNAs.On 11/24/25 at 1:00 PM, CNA #3 stated that Resident #1's verbal and physical aggression was directed toward CNAs and confirmed being struck herself.On 11/24/25 at 5:35 PM, Registered Nurse #1 stated she was aware of the behavior concerns but had not witnessed them herself.

She stated behavior concerns should be reflected in the care plan, which is used by all staff to direct care.On 11/24/25 at 5:47 PM, CNA #4 stated she uses the care plan to guide her care provision.On 11/24/25 at 5:55 PM, 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.A record review of Resident #1's admission Record revealed an admission date of 9/30/25 with diagnoses including cerebral infarction, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety.A record review of progress notes revealed behavioral incidents including:10/12/25 - Combative behavior toward CNA; 10/18/25 Slapped a CNA in the face and kicked her in the chest; 10/20/25 - Slapped a CNA in the face and pulled her hair down and punched her in the face; 10/18/25 - Hit a nurse in the abdomen; 11/02/25 - Punched a CNA with a closed fist.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date of 10/7/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitive intactness.

The MDS with ARD 10/24/25 coded for physical behavioral symptoms directed toward others and verbal behavioral symptoms directed toward others.A record review of the comprehensive care plan revealed no documentation of person-centered goals and interventions to address Resident #1's repeated verbal and physical aggression toward staff.

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.

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