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Brookhaven Manor

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About Brookhaven Manor

General Information

Legal Business NameKingsport Nh Operations, LLC
Ownership TypeFor Profit - Partnership
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareJuly 24, 1985 (32 years)
Capacity180
Residents105
Percent Occupied58%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Brookhaven Manor

Brookhaven Manor
was reviewed by Medicare to have a rating of 1 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Tennessee Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

December 7, 2016 - 4 months ago

 Residents AffectedSeveritySource/TypeDescription
KSomeImmediate JeopardyHealth InspectionMake sure that the facility is administered in an acceptable way that maintains the well-being of each resident .
KSomeImmediate JeopardyHealth InspectionHave enough nurses to care for every resident in a way that maximizes the resident's well being.
KSomeImmediate JeopardyHealth InspectionEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility
KSomeImmediate JeopardyHealth Inspection1) 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.
KSomeImmediate JeopardyHealth InspectionSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
KSomeImmediate JeopardyHealth InspectionProtect each resident from all abuse, physical punishment, and involuntary separation from others.
KSomeImmediate JeopardyHealth InspectionChoose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility.
JFewImmediate JeopardyHealth InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
JFewImmediate JeopardyHealth InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
JFewImmediate JeopardyHealth InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
JFewImmediate JeopardyHealth InspectionAllow residents the right to participate in the planning or revision of care and treatment.
JFewImmediate JeopardyHealth InspectionProtect each resident from mistreatment, neglect and misappropriation of personal property.
JFewImmediate JeopardyHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
JFewImmediate JeopardyHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
FManyPotential for HarmHealth InspectionProvide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
GFewActual HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionMaintain comfortable sound levels.
CManyPotential for Minimal HarmHealth InspectionPost nurse staffing information/data on a daily basis.
DFewPotential for HarmHealth InspectionUpon the death of a resident, convey the residentís personal funds and an accounting of those funds to the appropriate party.
DFewPotential for HarmHealth InspectionDispose of garbage and refuse properly.
DFewPotential for HarmHealth InspectionCoordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients.

November 10, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmHealth InspectionEnsure 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.
DFewPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmHealth InspectionUpon the death of a resident, convey the residentís personal funds and an accounting of those funds to the appropriate party.
DFewPotential for HarmHealth InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

October 20, 2015 - 18 months ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintHave a program that investigates, controls and keeps infection from spreading.

January 27, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintProtect each resident from mistreatment, neglect and misappropriation of personal property.
ESomePotential for HarmComplaintLet residents choose whether to manage their own money or deposit it with the nursing home.

September 10, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
DFewPotential for HarmHealth InspectionEnsure 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.
DFewPotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .

July 17, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
ESomePotential for HarmComplaintListen to the resident groups and act on their complaints and suggestions that affect resident care and life.
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

April 2, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintProvide resident groups or resident family groups with private space to meet.
ESomePotential for HarmComplaintProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
DFewPotential for HarmComplaintAllow residents the right to participate in the planning or revision of care and treatment.
DFewPotential for HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmComplaintGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
DFewPotential for HarmComplaintProvide medically-related social services to help each resident achieve the highest possible quality of life.
DFewPotential for HarmComplaintKeep each resident free from physical restraints, unless needed for medical treatment.
DFewPotential for HarmComplaint1) 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.
DFewPotential for HarmComplaintDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
DFewPotential for HarmComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
DFewPotential for HarmComplaintProtect each resident from mistreatment, neglect and misappropriation of personal property.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Brookhaven Manor require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

1hr 30min
2hr 25min
ReportedExpected
CNA
40min
40min
ReportedExpected
LPN
20min
1hr 5min
ReportedExpected
RN
2hr 35min
4hr 15min
ReportedExpected
Total Nursing

This facility also provides approximately 30min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

99.0%
98.9%
98.9%
98.9%
93.2%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
100.0%
98.8%
95.1%
96.6%
91.5%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
52.4%
40.9%
36.4%
50.0%
55.0%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of low risk long-stay residents who lose control of their bowels or bladder
43.6%
48.1%
49.4%
52.9%
36.8%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents who received an antianxiety or hypnotic medication
0.0%
6.5%
11.5%
13.7%
21.0%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents whose ability to move independently worsened
13.5%
14.1%
20.0%
19.8%
18.6%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents who received an antipsychotic medication
5.9%
8.3%
15.5%
8.1%
15.7%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents whose need for help with daily activities has increased
5.1%
11.8%
4.3%
6.3%
5.3%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents who self-report moderate to severe pain
12.7%
6.1%
2.5%
12.4%
8.0%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents who lose too much weight
4.5%
6.2%
10.9%
8.0%
5.3%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of high risk long-stay residents with pressure ulcers
9.3%
12.3%
6.2%
2.4%
2.4%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents who have depressive symptoms
5.1%
0.0%
0.0%
0.0%
5.4%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents with a urinary tract infection
5.0%
3.6%
3.7%
4.5%
3.3%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents experiencing one or more falls with major injury
3.5%
2.7%
2.8%
3.2%
2.6%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents with a catheter inserted and left in their bladder
2.5%
2.4%
2.5%
0.0%
1.6%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

88.6%
86.8%
89.2%
88.0%
81.7%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
88.9%
84.8%
84.8%
84.8%
80.0%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
30.9%
41.0%
58.6%
64.9%
61.7%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of short-stay residents who made improvements in function
27.8%
33.0%
31.8%
13.3%
14.0%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of short-stay residents who self-report moderate to severe pain
1.6%
1.6%
0.0%
0.0%
2.2%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of short-stay residents who newly received an antipsychotic medication
2.2%
1.6%
0.8%
0.9%
0.8%
Q4 2015Q1 2016Q2 2016Q3 2016TN
Percentage of short-stay residents with pressure ulcers that are new or worsened