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
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
0.34
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.84
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.40
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
4.79
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,107
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.25% · Performance 21.25% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.75% · Performance 8.20% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.15
Baseline 50.00% · Performance 54.90% · Measure score 2.15 · Achievement 2.15 · Improvement 0
Adjusted total nurse staffing
1.19
Baseline 2.82 hours · Performance 3.32 hours · Measure score 1.19 · Achievement 0.86 · Improvement 1.19
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.76% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 16.67% · Lower 95% interval 7.31% |
| Discharge to community | 46.45% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 39.58% · Lower 95% interval 35.43% |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 93.33% |
95.27%
1.9 pts worse
|
Numerator 42 · Denominator 45 |
| Falls with major injury | 4.44% |
0.77%
3.7 pts worse
|
Numerator 2 · Denominator 45 |
| Discharge self-care score | 42.31% |
53.69%
11.4 pts worse
|
Numerator 11 · Denominator 26 |
| Discharge mobility score | 46.15% |
50.94%
4.8 pts worse
|
Numerator 12 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 2.22% |
2.29%
0.1 pts better
|
Numerator 1 · Denominator 45 · Adjusted rate 1.81% |
| Healthcare-associated infections requiring hospitalization | 8.2% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 12.5% · Lower 95% interval 4.46% |
| Staff COVID-19 vaccination coverage | 72.81% |
8.2%
64.6 pts better
|
Numerator 83 · Denominator 114 |
| Staff flu vaccination coverage | 1.75% |
42%
40.2 pts worse
|
Numerator 2 · Denominator 114 |
| Discharge function score | 53.85% |
56.45%
2.6 pts worse
|
Numerator 14 · Denominator 26 |
| Transfer of health information to provider | 95% |
95.95%
1 pts worse
|
Numerator 19 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 25 |
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 · Adjusted 2.0 · Observed 1.8 · Expected 1.7 · Used in QM five-star |
| 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 · Adjusted 7.1 · Observed 6.5 · Expected 1.5 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 80.3% · Q3 100.0% · Q4 100.0% · 4Q avg 95.0% |
| 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 · 4Q avg 94.4% |
| 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 · Q1 1.5% · Q2 3.0% · Q3 1.6% · Q4 1.6% · 4Q avg 1.9% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 9.8% · Q2 17.7% · Q3 3.5% · Q4 9.1% · 4Q avg 10.2% |
| 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 · Q1 16.1% · Q2 19.4% · Q3 22.8% · Q4 22.8% · 4Q avg 20.2% |
| 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 · Q1 4.1% · Q2 11.6% · Q3 11.4% · Q4 10.9% · 4Q avg 9.3% · 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 | 18.1% |
22.8%
4.7 pts better
|
16.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 33.2% · Q3 12.3% · Q4 7.0% · 4Q avg 18.1% · Used in QM five-star |
| 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 · Q1 27.3% · Q2 24.6% · Q3 26.9% · Q4 18.5% · 4Q avg 24.3% · Used in QM five-star |
| 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 · Q1 1.3% · Q2 1.4% · Q3 1.6% · Q4 1.2% · 4Q avg 1.4% · Used in QM five-star |
| 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 · Q1 6.1% · Q2 3.0% · Q3 8.1% · Q4 0.0% · 4Q avg 4.3% · Used in QM five-star |
| 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 · Q1 22.0% · Q2 31.3% · Q3 34.9% · Q4 18.6% · 4Q avg 26.8% |
| 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 · Q1 3.1% · Q2 10.5% · Q3 6.2% · Q4 0.0% · 4Q avg 5.0% · Used in QM five-star |
| 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 · Q1 100.0% · Q2 91.7% · Q3 97.1% · Q4 100.0% · 4Q avg 97.2% |
| 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 · Adjusted 29.1% · Observed 31.7% · Expected 12.2% · Used in QM five-star |
| 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 · 4Q avg 4.0% · Used in QM five-star |
| 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 · 4Q avg 91.3% |
| 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 · Adjusted 27.8% · Observed 29.3% · Expected 25.1% · Used in QM five-star |
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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