Cycle 1
Health 2024-10-10 · Fire 2024-10-10
4 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Brookhaven, MS
Trend Health And Rehab Of Brookhaven
5-star overall rating with 4-star inspections with 4 recent health deficiencies
525 Brookman Drive, Brookhaven, MS
(601) 833-2330
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
58
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trend Consultants
Operator or chain grouping
Approved since
1993-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 3 overall / 3 health / 4 staffing / 2 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
0.58
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.81
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.27
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
0.70
CMS adjusted RN staffing hours
Adjusted total hours
4.62
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
22%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,324
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.56
Composite VBP score used to determine payment impact.
Payment multiplier
1.0127
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.58
Baseline 19.42% · Performance 19.77% · Measure score 3.58 · Achievement 3.58 · Improvement 0
Healthcare-associated infections
6.13
Baseline 9.42% · Performance 6.49% · Measure score 6.13 · Achievement 4.51 · Improvement 6.13
Total nurse turnover
6.68
Baseline 47.06% · Performance 36.36% · Measure score 6.68 · Achievement 6.68 · Improvement 4.32
Adjusted total nurse staffing
6.64
Baseline 3.75 hours · Performance 4.97 hours · Measure score 6.64 · Achievement 6.64 · Improvement 5.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.32% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 11.84% · Lower 95% interval 7.34% |
| Discharge to community | 60.96% |
50.57%
10.4 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 58.93% · Lower 95% interval 48.95% |
| Medicare spending per beneficiary | 1.38 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 41 · Denominator 41 |
| Falls with major injury | 12.2% |
0.77%
11.4 pts worse
|
Numerator 5 · Denominator 41 |
| Discharge self-care score | 58.33% |
53.69%
4.6 pts better
|
Numerator 14 · Denominator 24 |
| Discharge mobility score | 54.17% |
50.94%
3.2 pts better
|
Numerator 13 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 2.44% |
2.29%
0.1 pts worse
|
Numerator 1 · Denominator 41 · Adjusted rate 2.06% |
| Healthcare-associated infections requiring hospitalization | 6.49% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 2.63% · Lower 95% interval 3.62% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 70 |
| Staff flu vaccination coverage | 31.25% |
42%
10.8 pts worse
|
Numerator 25 · Denominator 80 |
| Discharge function score | 62.5% |
56.45%
6 pts better
|
Numerator 15 · Denominator 24 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| 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 | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.4
1 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.8 |
2.9
1.9 pts worse
|
1.8
3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.8 · Observed 4.0 · Expected 1.4 · 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 | 8.1% |
3.2%
4.9 pts worse
|
3.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 7.7% · Q3 9.4% · Q4 7.4% · 4Q avg 8.1% · 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 | 5.9% |
6.1%
0.2 pts better
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.3% · Q3 4.2% · Q4 12.8% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.9% |
24.4%
7.5 pts worse
|
19.6%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 36.2% · Q3 29.2% · Q4 25.5% · 4Q avg 31.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.6% |
23.4%
2.8 pts better
|
16.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 20.0% · Q3 19.4% · Q4 19.4% · 4Q avg 20.6% · 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 | 19.0% |
22.8%
3.8 pts better
|
16.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 24.8% · Q3 10.9% · Q4 14.5% · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.0% |
20.6%
4.6 pts better
|
14.9%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 20.9% · Q3 11.9% · Q4 16.3% · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.5%
1.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.7% |
2.5%
4.2 pts worse
|
1.7%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.9% · Q3 5.7% · Q4 11.1% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.1% |
21.4%
3.3 pts better
|
19.8%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 21.3% · Q3 17.8% · Q4 21.6% · 4Q avg 18.1% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
6.9%
0.6 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 13.2% · Q3 5.8% · Q4 1.5% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.3% |
87.9%
1.4 pts better
|
81.7%
7.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 100.0% · Q3 92.0% · Q4 68.2% · 4Q avg 89.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.1% |
15.3%
4.8 pts worse
|
12.0%
8.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 18.8% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
2.6%
0.5 pts better
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.9% |
84.6%
8.7 pts worse
|
79.7%
3.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
27.9%
3.6 pts better
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 21.9% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-09 · Fire 2023-03-09
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2019-08-08 · Fire 2019-08-08
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-03-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-04-07
F · Potential for more than minimal harm
2019-08-08
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-10-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-10
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 2024-11-01
D · Potential for more than minimal harm
2024-10-10
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 2024-11-01
D · Potential for more than minimal harm
2024-10-10
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-11-01
D · Potential for more than minimal harm
2023-08-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-04
E · Potential for more than minimal harm
2023-03-09
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-04-19
E · Potential for more than minimal harm
2023-03-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-19
D · Potential for more than minimal harm
2023-03-09
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 2023-04-19
F · Potential for more than minimal harm
2019-08-08
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 2019-09-25
E · Potential for more than minimal harm
2019-08-08
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 2019-09-25
D · Potential for more than minimal harm
2019-08-08
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2019-09-25
D · Potential for more than minimal harm
2019-08-08
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2019-09-25
D · Potential for more than minimal harm
2019-08-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-09-25
D · Potential for more than minimal harm
2019-08-08
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 2019-09-25
D · Potential for more than minimal harm
2019-08-08
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 2019-09-25
D · Potential for more than minimal harm
2019-08-08
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 2019-09-25
D · Potential for more than minimal harm
2019-08-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-25
Penalties and ownership
What sits behind the stars
Ownership
Kelly, Charles
5% Or Greater Direct Ownership Interest · Individual
Barlow, Dannie
Corporate Director · Individual
Deer, Hayley
Corporate Officer · Individual
Johnson, Denise
W-2 Managing Employee · Individual
Warnock, Lori
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Diversicare Of Brookhaven
Brookhaven, MS
2-star overall rating with 2-star inspections with abuse icon flag with $8,788 in total fines with 14 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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