Cycle 1
Health 2025-12-11 · Fire 2025-12-11
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Brookhaven, MS
Silver Cross Health & Rehab
3-star overall rating with 3-star inspections with 11 recent health deficiencies
503 Silver Cross Drive, Brookhaven, MS
(601) 833-2361
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Advanced Health Care Management
Operator or chain grouping
Approved since
2005-01-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 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
0.41
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.06
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
2.46
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,655
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9963
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.07
Baseline 23.22% · Performance 19.77% · Measure score 5.07 · Achievement 3.58 · Improvement 5.07
Healthcare-associated infections
5.43
Baseline 10.56% · Performance 7.26% · Measure score 5.43 · Achievement 1.92 · Improvement 5.43
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
2.49
Baseline 3.83 hours · Performance 3.79 hours · Measure score 2.49 · Achievement 2.49 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.93% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 164 · Observed rate 8.54% · Lower 95% interval 6.85% |
| Discharge to community | 69.7% |
50.57%
19.1 pts better
|
Better than the National Rate · Eligible stays 130 · Observed rate 71.54% · Lower 95% interval 61.67% |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 105 · Denominator 105 |
| Falls with major injury | 1.9% |
0.77%
1.1 pts worse
|
Numerator 2 · Denominator 105 |
| Discharge self-care score | 54.79% |
53.69%
1.1 pts better
|
Numerator 40 · Denominator 73 |
| Discharge mobility score | 58.9% |
50.94%
8 pts better
|
Numerator 43 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 2.86% |
2.29%
0.6 pts worse
|
Numerator 3 · Denominator 105 · Adjusted rate 2.57% |
| Healthcare-associated infections requiring hospitalization | 7.26% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 6.06% · Lower 95% interval 4.26% |
| Staff COVID-19 vaccination coverage | 1.37% |
8.2%
6.8 pts worse
|
Numerator 1 · Denominator 73 |
| Staff flu vaccination coverage | 28.41% |
42%
13.6 pts worse
|
Numerator 25 · Denominator 88 |
| Discharge function score | 64.38% |
56.45%
7.9 pts better
|
Numerator 47 · Denominator 73 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 58 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.4
1.1 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.9 |
2.9
1 pts worse
|
1.8
2.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 4.0 · Expected 1.7 · 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 | 6.4% |
3.2%
3.2 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.0% · Q3 4.9% · Q4 6.5% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
1.6%
0.3 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
6.1%
3 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.1% · Q3 6.2% · Q4 0.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.5% |
24.4%
7.1 pts worse
|
19.6%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 31.2% · Q3 34.4% · Q4 32.4% · 4Q avg 31.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.3% |
23.4%
19.1 pts better
|
16.7%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 6.7% · Q4 6.5% · 4Q avg 4.3% · 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 | 30.1% |
22.8%
7.3 pts worse
|
16.3%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.4% |
20.6%
11.2 pts better
|
14.9%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 21.4% · Q3 3.3% · Q4 3.2% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.5%
1.5 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.5%
0.5 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 4.7% · Q3 2.4% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.5% |
21.4%
1.9 pts better
|
19.8%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 33.5% · Q2 21.0% · Q3 18.0% · Q4 7.9% · 4Q avg 19.5% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
6.9%
1.6 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 14.8% · Q3 4.6% · Q4 1.8% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
87.9%
11.2 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 100.0% · Q3 98.1% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.7% |
15.3%
0.4 pts worse
|
12.0%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 15.1% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.6%
2.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.4% |
84.6%
13.8 pts better
|
79.7%
18.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
27.9%
6.3 pts better
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 19.4% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2024-05-16
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-11-22 · Fire 2022-11-22
2 health deficiencies
Top issue: Pharmacy Service (2 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
2024-05-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-11
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 2026-01-26
E · Potential for more than minimal harm
2025-12-11
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 2026-01-26
D · Potential for more than minimal harm
2025-12-11
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 2026-01-26
D · Potential for more than minimal harm
2025-12-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2026-01-26
D · Potential for more than minimal harm
2025-12-11
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2026-01-26
D · Potential for more than minimal harm
2025-12-11
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 2026-01-26
D · Potential for more than minimal harm
2025-12-11
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 2026-01-26
D · Potential for more than minimal harm
2025-12-11
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2026-01-26
D · Potential for more than minimal harm
2025-12-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-26
D · Potential for more than minimal harm
2025-12-11
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2026-01-26
D · Potential for more than minimal harm
2025-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-26
D · Potential for more than minimal harm
2024-05-16
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 2024-06-29
D · Potential for more than minimal harm
2024-05-16
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 2024-06-29
D · Potential for more than minimal harm
2024-05-16
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 2024-06-29
D · Potential for more than minimal harm
2024-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-29
D · Potential for more than minimal harm
2022-11-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-22
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 2022-12-30
Penalties and ownership
What sits behind the stars
Ownership
Lincoln Ltc LLC
5% Or Greater Direct Ownership Interest · Organization
Dt Investments LLC
5% Or Greater Indirect Ownership Interest · Organization
Griffin, Troy
5% Or Greater Indirect Ownership Interest · Individual
Griffin, Troy
Operational/Managerial Control · Individual
Hubbard, Brien
5% Or Greater Indirect Ownership Interest · Individual
Hubbard, Gene
5% Or Greater Indirect Ownership Interest · Individual
Hubbard, Gene
Operational/Managerial Control · Individual
Providence Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
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#3
Haven Hall Health Care Center
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