Cycle 1
Health 2024-10-31 · Fire 2024-10-31
3 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Brookhaven, MS
Haven Hall Health Care Center
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
101 Mills Street, Brookhaven, MS
(601) 833-5608
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
81
Certified beds
Average residents
70
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.34
Registered nurse staffing
LPN hours / resident day
1.05
Licensed practical nurse staffing
Aide hours / resident day
2.46
Nurse aide staffing
Weekend hours
3.40
Weekend nurse staffing
RN turnover
29%
Annual RN turnover
Total nurse turnover
58%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.4
0.4 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 7.1 |
2.9
4.2 pts worse
|
1.8
5.3 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
95.7%
0.7 pts worse
|
93.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.4% |
97.0%
2.6 pts worse
|
95.5%
1.1 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.2%
1.3 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.6%
1.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 10.2% |
6.1%
4.1 pts worse
|
5.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.2% |
24.4%
4.2 pts better
|
19.6%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 9.3% |
23.4%
14.1 pts better
|
16.7%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.1% |
22.8%
4.7 pts better
|
16.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.3% |
20.6%
3.7 pts worse
|
14.9%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.5%
0.1 pts better
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
2.5%
1.8 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.8% |
21.4%
5.4 pts worse
|
19.8%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
6.9%
1.9 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
87.9%
9.3 pts better
|
81.7%
15.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 29.1% |
15.3%
13.8 pts worse
|
12.0%
17.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.0% |
2.6%
1.4 pts worse
|
1.6%
2.4 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.3% |
84.6%
6.7 pts better
|
79.7%
11.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.8% |
27.9%
0.1 pts better
|
23.9%
3.9 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-28 · Fire 2023-06-28
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-02-20 · Fire 2020-02-20
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-31
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-10-31
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 2024-12-06
D · Potential for more than minimal harm
2024-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-03-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-17
J · Immediate jeopardy
2023-08-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-06-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-26
J · Immediate jeopardy
2020-02-20
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 2020-03-02
J · Immediate jeopardy
2020-02-20
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2020-03-02
J · Immediate jeopardy
2020-02-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-03-02
J · Immediate jeopardy
2020-02-20
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2020-03-02
F · Potential for more than minimal harm
2020-02-20
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 2020-03-02
D · Potential for more than minimal harm
2020-02-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-03-09
Penalties and ownership
What sits behind the stars
$9,445
2023-08-24
Fine
Fine · fine $9,445
Fine
Ownership
Daspit, Richard
Corporate Director · Individual
Joyce, Kimberly
Corporate Officer · Individual
Peeler, Lonnie
Operational/Managerial Control · Individual
Peeler, Lonnie
Corporate Officer · Individual
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