Cycle 1
Health 2026-01-08 · Fire 2026-01-08
14 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Brookhaven, MS
Diversicare Of Brookhaven
2-star overall rating with 2-star inspections with abuse icon flag with $8,788 in total fines with 14 recent health deficiencies
519 Brookman Drive, Brookhaven, MS
(601) 833-2881
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
58
Certified beds
Average residents
48
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Diversicare Healthcare
Operator or chain grouping
Approved since
1994-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
44 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.76
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
4.00
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.74
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.45
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.91
CMS adjusted RN staffing hours
Adjusted total hours
4.78
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,806
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.63% · Performance 24.21% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.26% · Performance 7.94% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.77
Baseline 32.20% · Performance 48.28% · Measure score 3.77 · Achievement 3.77 · Improvement 0
Adjusted total nurse staffing
3.85
Baseline 4.88 hours · Performance 4.17 hours · Measure score 3.85 · Achievement 3.85 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.13% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 120 · Observed rate 13.33% · Lower 95% interval 9.08% |
| Discharge to community | 67.29% |
50.57%
16.7 pts better
|
Better than the National Rate · Eligible stays 103 · Observed rate 66.02% · Lower 95% interval 58.43% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.14% |
95.27%
1.9 pts better
|
Numerator 68 · Denominator 70 |
| Falls with major injury | 1.43% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 70 |
| Discharge self-care score | 47.83% |
53.69%
5.9 pts worse
|
Numerator 22 · Denominator 46 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 23 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 2.86% |
2.29%
0.6 pts worse
|
Numerator 2 · Denominator 70 · Adjusted rate 2.79% |
| Healthcare-associated infections requiring hospitalization | 7.94% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 64 · Observed rate 9.38% · Lower 95% interval 4.16% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 90 |
| Staff flu vaccination coverage | 79.13% |
42%
37.1 pts better
|
Numerator 91 · Denominator 115 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 23 · Denominator 46 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 51 · Denominator 51 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 21.43% |
25.2%
3.8 pts worse
|
Numerator 6 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.2 |
2.4
0.8 pts worse
|
1.9
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 2.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.1 |
2.9
2.2 pts worse
|
1.8
3.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.1 · Observed 4.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.0%
3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.2%
2.5 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
1.6%
2.1 pts worse
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.6% · Q3 3.1% · Q4 3.2% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 13.3% |
6.1%
7.2 pts worse
|
5.4%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 10.5% · Q3 16.1% · Q4 12.5% · 4Q avg 13.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.7% |
24.4%
1.3 pts worse
|
19.6%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 28.2% · Q3 24.2% · Q4 21.9% · 4Q avg 25.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.4% |
23.4%
12 pts better
|
16.7%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 9.4% · Q3 14.3% · Q4 3.7% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.9% |
22.8%
18.9 pts better
|
16.3%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.7% |
20.6%
3.9 pts better
|
14.9%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 12.8% · Q3 9.4% · Q4 15.6% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.5%
0.4 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
2.5%
0.9 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 7.5% · Q3 0.0% · Q4 2.9% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.3% |
21.4%
3.9 pts worse
|
19.8%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 31.9% · Q3 11.7% · Q4 28.2% · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
6.9%
0.5 pts better
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 6.0% · Q3 7.4% · Q4 6.1% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
87.9%
12.1 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 30.0% |
15.3%
14.7 pts worse
|
12.0%
18 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.0% · Observed 29.6% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
2.6%
1.3 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 1.2% · Q4 1.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
84.6%
11.1 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.4% |
27.9%
3.5 pts worse
|
23.9%
7.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.4% · Observed 31.5% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-20 · Fire 2024-06-20
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-12-01 · Fire 2022-12-01
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-09
E · Potential for more than minimal harm
2026-01-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-02-09
D · Potential for more than minimal harm
2026-01-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-02-09
D · Potential for more than minimal harm
2026-01-08
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2026-02-09
D · Potential for more than minimal harm
2026-01-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-09
D · Potential for more than minimal harm
2025-11-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-12-12
E · Potential for more than minimal harm
2025-11-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-11-21
E · Potential for more than minimal harm
2025-11-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-11-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-11-21
G · Actual harm
2025-06-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-02
E · Potential for more than minimal harm
2025-06-04
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-02
D · Potential for more than minimal harm
2025-06-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-02
D · Potential for more than minimal harm
2025-06-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-02
D · Potential for more than minimal harm
2025-06-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-02
D · Potential for more than minimal harm
2024-06-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-26
B · Minimal harm
2024-06-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-03-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-05-02
D · Potential for more than minimal harm
2023-08-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-08-31
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-10-03
F · Potential for more than minimal harm
2022-12-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-05
E · Potential for more than minimal harm
2022-12-01
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-12-01
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-12-01
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-12-01
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-01-05
Penalties and ownership
What sits behind the stars
$8,788
2025-06-04
Fine
Fine · fine $8,788
Fine
Ownership
Diversicare Leasing Company Iii LLC
5% Or Greater Direct Ownership Interest · Organization
Advocat Finance, LLC
5% Or Greater Indirect Ownership Interest · Organization
Bodie, Rebecca
Corporate Officer · Individual
Canova, Charolett
Operational/Managerial Control · Individual
Dac Acquisition LLC
5% Or Greater Indirect Ownership Interest · Organization
Dac Newcorp Inc
5% Or Greater Indirect Ownership Interest · Organization
Diversicare Healthcare Services LLC
5% Or Greater Indirect Ownership Interest · Organization
Diversicare Management Services LP.
5% Or Greater Indirect Ownership Interest · Organization
Diversicare Management Services LP.
Operational/Managerial Control · Organization
Diversicare Of Brookhaven LLC
Operational/Managerial Control · Organization
Hodges, Cole
Operational/Managerial Control · Individual
Kellman, Franklin
Corporate Director · Individual
Kohn, Brian
Corporate Director · Individual
Nee, Stephen
Corporate Officer · Individual
Ratner, Eran
Corporate Director · Individual
Ratner, Eran
Corporate Officer · Individual
Weishaar, Matthew
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Trend Health And Rehab Of Brookhaven
Brookhaven, MS
5-star overall rating with 4-star inspections with 4 recent health deficiencies
#2
Silver Cross Health & Rehab
Brookhaven, MS
3-star overall rating with 3-star inspections with 11 recent health deficiencies
#3
Haven Hall Health Care Center
Brookhaven, MS
4-star overall rating with 4-star inspections with $9,445 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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