HAVEN HALL HEALTH CARE CENTER

Nursing Home Inspector

101 MILLS STREET
BROOKHAVEN, MS 39601
Lincoln County
Phone: 601-833-5608
Provider Number: 255221
Last Inspection: 04/20/2017

About the Nursing Home

Number of Beds: 81
Number of Residents: 59
Beds Available: 22
Percent Occupancy: 73%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

7

Facility
9

County
11

MS
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

7

2017
26

2016
9

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

4/20/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 5/20/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 5/20/2017
 

2/5/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 3/5/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Actual 4 3/5/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Actual 4 3/5/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 3/5/2016
 
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Actual 4 3/5/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 3/5/2016
 
Failed To: Provide bedrooms that don't allow residents to see each other when privacy is needed. Isolated : Minimal 3 3/5/2016
 

4/30/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 6/12/2015
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 6/12/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 6/12/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

6/21/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 7/17/2017
 

2/6/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 3/10/2017
 

7/19/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 8/12/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MS State Avg
Number of Residents 59 59.75 77.87
Registered Nurses 0.34 0.57 0.78
Licensed Practical / Vocational Nurses 1.19 0.73 0.98
Certified Nursing Assistants 2.18 1.39 2.33
Total Staff Hours 3.71 2.70 4.09

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MS State Avg%
of high risk long-stay residents with pressure ulcers 11 8 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 99 97
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100 99 96
of long-stay residents experiencing one or more falls with major injury 3 3 3
of long-stay residents who have depressive symptoms 2 2 1
of long-stay residents who lose too much weight 17 9 7
of long-stay residents who received an antianxiety or hypnotic medication 28 35 26
of long-stay residents who received an antipsychotic medication 17 18 19
of long-stay residents who self-report moderate to severe pain 13 5 8
of long-stay residents who were physically restrained 0 0 1
of long-stay residents whose ability to move independently worsened 29 24 18
of long-stay residents whose need for help with daily activities has increased 17 14 16
of long-stay residents with a catheter inserted and left in their bladder 1 1 2
of long-stay residents with a urinary tract infection 0 3 4
of low risk long-stay residents who lose control of their bowels or bladder 42 48 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 100 84 87
of short-stay residents who had an outpatient emergency department visit 16 20 14
of short-stay residents who made improvements in function 58 66 62
of short-stay residents who newly received an antipsychotic medication 4 2 2
of short-stay residents who self-report moderate to severe pain 24 13 15
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 100 90 84
of short-stay residents who were rehospitalized after a nursing home admission 19 23 24
of short-stay residents who were successfully discharged to the community 48 53 41
of short-stay residents with pressure ulcers that are new or worsened 0 0 0