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Nmmc Baldwyn Nursing Facility

739 4th Street South, Baldwyn, MS 38824 · Non profit - Corporation · 107 certified beds · (662) 365-4091 Medicare & Medicaid certified

Call the home — (662) 365-4091 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0565)1 actual-harm citation$8,788 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • it has a citation for mishandling residents’ money or property (F0565)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,788 in federal fines (most recent 2025-11-04)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
529 S 4th St · (662) 365-2222 · Call to confirm hours
Pharmacy
735 S 4th St · (662) 365-5036 · Call to confirm hours
Grocery
218 MS-145 · (662) 365-7411 · Call to confirm hours
Park
Charlotte St · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.6%20.5%15.4%better
Long-stay residents who lose too much weight11.7%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder1.7%1.4%0.9%worse
Long-stay residents with a urinary tract infection1.3%2.5%2.0%better
Long-stay residents with depressive symptoms1.5%1.6%6.5%typical for the state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury2.9%3.1%3.3%better
Long-stay residents whose ability to walk worsened14.1%19.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication24.0%23.8%18.9%worse
Long-stay residents given the seasonal flu vaccine90.8%97.0%95.3%typical
Long-stay residents with pressure ulcers10.1%6.3%4.7%worse
Long-stay residents with worsening bladder/bowel control21.7%20.7%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table22.4%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%2.5%1.4%better
Short-stay residents given the seasonal flu vaccine75.3%84.6%79.4%typical
Short-stay residents rehospitalized after admission29.9%27.7%22.6%worse
Short-stay residents with an outpatient ER visit10.7%15.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.152.431.67better
Long-stay outpatient ER visits per 1,000 resident days1.012.861.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

62.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 77 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.4%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
72.5%U.S. median 56.6%
Met the expected recovery
0.14U.S. median 0.31
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 72.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 40 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF62.4%CMS range 48.5–73.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 6.9–14.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge72.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge57.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge55.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting0.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge8.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened7.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.6%CMS range 3.6–9.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.921.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.04
RN hours/ resident / day
0.62
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.87
Total nurse hours/ resident / day
0.82
RN hoursweekends
46.1%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 107 beds and averages 100.3 residents a day — about 94% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.87 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.04 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.34 hrs/resident/day on weekends vs 4.09 on weekdays — 18% thinner on weekends. RN hours go from 1.13 to 0.82 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

11
deficiencies at the latest standard inspection (2026-03-26)
4
at the previous standard inspection (2025-01-09)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited before2025-11-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure skin care treatments were completed as ordered for one (1) of three (3) residents reviewed for wound and skin care. This deficient practice resulted in deterioration of a resident's wound, including a significant increase in wound size for Resident #1.Findings include:Review of the facility policy titled Skin and Wound Care, last reviewed 5/2/24, revealed: Policy: It is the policy that skin anomalies should be identified, and basic wound care should be provided.Resident #1During an onsite complaint survey, an interview with Resident #1 on 11/3/25 at 10:30 AM revealed she had wounds to her legs. Resident #1 stated she often does not get her dressing changed to her leg at night and sometimes during the day. Observation revealed a dressing to the left posterior leg.Review of wound care orders for Resident #1's left lower leg ulcer revealed orders dated 9/20/25, 10/14/25, and 10/22/25, with treatment intervals of two (2) times daily.Review of Resident #1's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-26 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, and facility policy review, the facility failed to provide sufficient nursing staff to ensure residents received necessary care as evidenced by failure to complete activities of daily living (ADL) care, including bathing, grooming, and nail care; failure to ensure call lights were answered in a timely manner; and failure to address repeated concerns voiced by residents during resident council meetings regarding delays in care and unmet needs for three (3) of four (4) survey days. Findings include: Review of the facility's policy titled, Scheduling of Nursing Staff with a revision date of 03/20, revealed under Policy: It is the policy of (Proper Name) to provide consistent expectations and standardized scheduling processes in staff schedules enabling appropriate staffing levels to ensure patient and staff safety. An observation and interview on 3/23/26 at 12:20 PM revealed Resident #10 with facial hair on the sides of his face, on his chin, and neck,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure informed consent was obtained prior to the initiation of a psychotropic medication for one (1) of two (2) residents reviewed for unnecessary medications. Resident #2 Findings include:Record review revealed the facility had no policy requiring psychotropic consent forms to be obtained prior to initiation of a psychotropic medication.Record review of Resident #2's Active Order Sets revealed an order dated 2/25/26 for Seroquel oral tablet 50 milligrams (mg) to be given by mouth at bedtime for non-Alzheimer's dementia and an order dated 2/25/26 for Buspar oral tablet 10 mg to be given three times daily for depression.Record review revealed the Psychotropic Medication Informed Consent Form was not signed until 3/23/26.On 3/26/2026 at 8:37 AM, during an interview with the Minimum Data Set (MDS) Consultant, she stated there should have been signed consent for Seroquel and Buspar prior to initiation; however, the facility did not obtain consents…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-26 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, record reviews, and facility policy reviews, the facility failed to implement a Catheter and Activities of Daily Living (ADL) care plan for five (5) of 25 resident care plans reviewed. (Resident #4, Resident #7, Resident #10, Resident #46, and Resident #54) Findings include: Record review of facility policy titled, Care Plan Policy with most recent revision date of 10/24, revealed, .In accordance with each resident's plan of care, all services provided or arranged by the facility should meet professional standards of quality and should be provided by qualified persons Resident #4 Record review of the Care Plan revealed, Requires a foley catheter related to neurogenic bladder.Approaches.Secure catheter to prevent trauma. On 3/24/26 at 2:10 PM during an interview and observation of catheter care by Certified Nursing Assistant (CNA) #2, it was noted that Resident #4 had an indwelling catheter. It was observed that no securing device was in place for the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure Activities of Daily Living (ADL) was provided to residents requiring assistance with personal hygiene for four (4) of the twenty-five sampled residents. (Residents #7, # 10, #46, and #54) Findings include: Record review of facility policy titled, AM/PM Care dated 10/24 revealed, Rationale: to provide guidelines to help promote resident cleanliness. Residents should be shaved per preference. Resident #7 During an observation with Resident #7 on 3/23/26 at 11:40 AM, the resident revealed she would like for her fingernails to be trimmed. Observation revealed the resident's fingernails were approximately one-half (1/2) inch in length. The resident was also observed to have dark chin hair approximately one-fourth (1/4) inch in length. During an observation with Resident #7 on 3/24/26 at 8:39 AM, the resident continued to request that her fingernails be trimmed. Observation revealed long…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review, and resident and staff interviews, the facility failed to ensure necessary treatment and care were provided to promote healing and prevent worsening of pressure ulcers for one (1) of four (4) residents reviewed for pressure ulcers (Resident #7). Findings include: Review of the facility policy titled Skin and Wound Care, last reviewed 5/2/24, revealed: Policy: It is the policy that skin anomalies should be identified, and basic wound care should be provided. Resident #7 An interview with Resident #7 on 3/25/26 at 2:00 PM revealed the resident was admitted with two wounds, one on the buttock and one on the sacrum. The resident stated one wound had healed and the sacral wound remained present. Record review of wound care orders for Resident #7's sacral stage four (4) pressure ulcer with physician orders dated 2/10/2026 with treatment intervals of two (2) times daily. Record review of the Treatment Administration Record (TAR) for March 2025 Flow Sheet for the sacral…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure adequate supervision and implementation of interventions to prevent accidents for one (1) of four (4) falls reviewed. Resident #65.Findings Include:Review of the facility policy titled Fall Prevention and Post Fall Assessment & (and) Follow-up revealed under, Rational: To provide guidelines for the identification of residents at risk for falls. To provide assessments, interventions, and documentation after a resident fall. Also revealed under, Policy: It is the policy of 'Proper name of the facility' to identify residents at risk for falls in the attempt to help prevent falls and resident falls should be handled appropriately. An observation outside Resident #65's room on 3/23/26 at 12:20 PM revealed that the door was closed. The resident was located on the window side of the room, and the center privacy curtain was pulled. Resident #65 was lying in bed, awake and non-verbal. The left side of the bed was against the wall and one-half (1/2) side rails were located on the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and facility policy review, the facility failed to provide a catheter securement device for a resident with an indwelling catheter for one (1) or four (4) catheters observed. Resident #4 Findings include: Resident #4 Record review of facility letterhead titled Catheter Care (if present) dated 3/25/26, revealed 5A. The catheter tubing should be secured with securement device to resident's upper portion of lower extremity (ex. Adhesive securement device, leg securement strap, or other approved device provided by [local hospital]). During an interview and observation of catheter care by Certified Nursing Assistant (CNA) #2 on 3/24/26 at 2:10 PM, it was noted that Resident #4 had an indwelling catheter. It was observed that no securing device was in place for the securement of the catheter. CNA #2 revealed that use of the device was required to secure the catheter in place and this must have fallen off. An interview on 3/24/26 at 2:20 PM with the Director of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, and facility policy review, the facility failed to ensure adequate nutritional support and implementation of physician-ordered interventions to prevent significant weight loss for one (1) of six (6) residents reviewed for nutrition. Resident #1 Findings Include: Review of the facility policy titled Weight Loss: Monitoring of unrevised, revealed under, Policy: It is the policy of 'Proper name of the facility 'that the weight and the nutritional status of residents be monitored. Also revealed under, Procedure: If a resident has a weight loss greater than 5 (five) percent of body weight in one month or 10 percent of body weight in a six month period, the dietician should be consulted and recommendations of dietician should be followed. Record review of Resident #1's Flowsheet History revealed the following weights: Record review of Resident #1's weights revealed on 9/17/2025, the resident weighed 135 pounds (lbs.). On 02/05/2026, the resident weighed 119 lbs., which was a significant weight loss of -11.85% (percent) in 6 months. On 12/11/2025,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure the safe use, assessment, and ongoing evaluation of bed rails and failed to identify and remove a known entrapment hazard for one (1) of 25 sampled residents. Resident #65 Findings Include: Record review of the facility policy titled Bed Rails revised 9/18, revealed under, Policy: It is the policy of 'Proper name of the facility' that bed rails should be used appropriately. This failed practice was not in accordance with facility policy requiring appropriate use and assessment of bed rails. An observation of Resident #65 on 3/23/26 at 12:20 PM revealed he was lying in bed, awake and non-verbal. The left side of the bed was against the wall and one-half (1/2) upper side rails were observed to the left and right side of the bed with a fall mat on the floor. Record review of Resident #65's Significant Event Note dated 3/3/26 revealed, I heard residents peg (percutaneous endoscopic gastrostomy) pump going off, upon entering room Director of Nursing (DON) was standing next to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-26 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility policy review, the facility failed to ensure medications and treatment solutions were secured and not accessible to the resident for three (3) of four (4) survey days. Findings Include: Review of the facility policy titled Medication Administration revised 3/11/24 revealed, 3. No medications should be left in the resident's room [ROOM NUMBER]. Storage of medications and several other associated products should be secure, i.e., in a locked drawer/cabinet, or under constant surveillance. An observation inside room C3 on 3/23/26 at 11:12 AM and again on 3/24/26 at 8:14 AM revealed four (4) bottles of Dakin's solution quarter-strength (1/4), 16 fluid ounce bottles; two (2) bottles sitting on a table beside the bed and the other two (2) in a pink pail by the sink. Other items stored on the counter by the sink included a bottle of ethyl alcohol, 16-ounce bottle 70% (percent), and hydrogen peroxide 3% (percent). An observation and interview with Licensed Practical…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2026-03-26 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility policy review, the facility failed to maintain effective infection control practices as evidenced by uncovered clean utility cart, staff not wearing gowns for enhanced barrier precautions, and handling soiled linens without a barrier bag, increasing the risk of cross-contamination and infection transmission for one (1) of four (4) survey days. Findings Include: Review of the facility's policy titled, EVS-Residential Laundry with an issued date of 4/1/18, revealed under Policy: All potentially contaminated linen should be handled with appropriate measures to prevent cross-transmission . Linen should be carried away from the body and clothing.Clean linens and residential laundry should be stored on clean, covered carts. Review of the facility's policy titled, Enhanced Barriers in Nursing Homes with an approved date of 4/5/24, revealed under Policy: It is the policy of Proper Name long term care facilities that appropriate infection control precautions be observed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure wound care treatments were completed as ordered for two (2) of three (3) residents reviewed for pressure ulcer wound care (Residents #2 and #3). Findings include:Review of the facility policy titled Skin and Wound Care, last reviewed 5/2/24, revealed: Policy: It is the policy that skin anomalies should be identified, and basic wound care should be provided. Resident #2An interview with Resident #2 on 11/3/25 at 11:00 AM revealed she had a wound on the back of her right leg. She confirmed there had been a few times over the past month that her treatment had not been completed.Record review of wound care orders for Resident #2's right upper leg stage (4) pressure injury (PI) revealed orders dated 8/21/25 and 10/20/25, with treatment intervals of daily.Record review of Resident #2's October/November 2025 Treatment Flow Sheet for the right upper posterior leg revealed the treatment was not completed as ordered five (5) times from 10/1/25 through 11/3/25.Record…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-30 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff and resident interview, record review, and facility policy review the facility failed to implement care plans for a dependent resident with a negative pressure wound therapy system (wound vac) in place and who required assistance with Activities of Daily Living for one (1) of four (4) residents sampled. Resident #1. Findings Include: Review of the facility policy, Care Plan Policy with reviewed date of 10/20 revealed, It is the policy of (Proper Name Facility) that care plans should be properly developed and implemented. Record review of Resident #1's Care Plan updated 04/11/25 revealed that she required assistance with ADL's (activities of daily living) related to End Stage Renal Disease on dialysis, Decreased Mobility, and Generalized Weakness. Resident #1's Care Plan Approaches included, to provide appropriate level of assistance with ADL's as needed and this included limited to extensive need for one person assistance with dressing. Record review of Resident #1's Wound/Skin Careplan dated 03/29/25, revealed that she had a surgical wound to her left…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review and facility policy review the facility failed to provide a dependent resident with assistance to change clothes prior to going to bed for one (1) of four (4) residents reviewed. Resident #1. Findings Include: Review of the facility policy AM/PM Care dated March 2020 revealed, .Resident's clothing should be changed daily and when soiled. On 04/29/25 at 9:47 AM, an interview with the complainant at the facility revealed that Resident #1, had been at the facility for a little over a year. She revealed that she had declined since admission into the facility and was now more dependent on the staff for her care. Activities Director revealed that she came into the facility one Saturday morning and found that Resident #1 had the same clothes on she had worn to dialysis the day before. She revealed that Resident #1 slept in her regular clothes frequently and she had witnesses that also observed this. She revealed that Resident #1 didn't live like that, she didn't sleep in her clothes at night before she came to the facility, and she shouldn't…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, the facility failed to provide treatment consistent with professional standards of practice to an existing surgical wound for one (1) of three (3) residents reviewed for wound care. Resident #1. Findings Include: Review of the facility policy Negative Pressure Wound Therapy System, Single Use dated 03/03/2025 revealed The pump may be disconnected from the dressing if there is a requirement to disconnect - such as the need to have a shower An interview on 04/29/25 at 10:00 AM with the complainant revealed that Resident #1, recently had an infected fistula removed from her left arm and she had a wound vac in place. The complainant revealed that she had a concern with the nurses not keeping the wound vac hooked up to suction all the time like they were supposed to. She revealed that Resident #1 went out to a doctor's appointment this morning and did not have the wound vac canister with her when she left. The complainant revealed that there had been several days that she observed that the wound vac was not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-30 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review and facility policy review, the facility failed to properly store medications needing refrigeration in one (1) of two (2) medication storage rooms. Station one (1) Medication Storage Room. Findings Include: Review of the facility policy, Medication Storage with last modified date of 03/14/2024, revealed, It is the policy of (proper name) that all medications should be appropriately delivered and stored. The policy also revealed under Security and Storage that Once the medications are removed from the designated storage area, the medications should remain with the licensed designated individual at all times and should not be left unattended An interview on 04/29/25 at 10:55 AM with Interim Director of Nursing (DON), revealed that they had a small refrigerator in each medication room with a lock box inside where they kept their narcotics that required refrigeration. She revealed that on 04/03/25, Licensed Practical Nurse (LPN) #1 was defrosting one of the medication refrigerators and realized that there was a problem with it. Interim DON revealed that…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-01-09 · tag F0851 — widespread
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and record review, the facility failed to submit accurate information into the Payroll Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. Fourth Quarter 2024 Findings include: Record review of facility policy titled, Staffing Guidelines, undated, revealed, Guidelines for Payroll Based Journal submission: 1. The facility shall submit staffing data to the Centers for Medicare and Medicaid Services (CMS) via CMS's Payroll Based Journal electronic data submission portal. 2. The facility shall submit staffing data in a uniform format according to specifications established by CMS. Record review of PBJ Staffing Data Report revealed the facility had Excessively Low Weekend Staffing for the fourth quarter of 2024. Upon entry into the facility on 1/6/25 at 9:10 AM, an interview with the Assistant Administrator revealed the facility had not been short staffed during the weekends or the week and he was uncertain why the PBJ report reflected that. He stated he would gather the necessary information for this concern. During an interview on 1/8/25 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-09 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident and staff interviews, and facility policy review, the facility failed to honor a resident right to vote in the 2024 election for one (1) of 23 sampled residents. Resident #72 Findings Include: Review of the facility policy titled Resident Rights: Participation in Groups and Activities of Choice with a review date of 2/12/24 revealed under, Procedure: . Residents should be encouraged to exercise their rights to vote in local, state, and national elections. An interview with Resident #72 on 1/8/24 at 8:11 AM revealed she had lived at the facility for over a year and did not get to vote this past election. She explained that she was registered to vote in a different county and had waited for the staff to bring her the necessary forms to complete, but no-one ever did. She revealed she always voted in the past, and it was important for her to continue to do so. An interview with Social Services (SS) on 1/8/24 at 10:10 AM revealed she did not go room to room and speak with the residents individually regarding their desire to vote in the past election. She explained that…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, and facility policy review, the facility failed to provide a clean, safe, and homelike environment as evidenced by bugs in ceiling lights, walls and ceiling in disrepair, blind slats broken and bent, broken wood molding, unclean air/heating unit and floors for six (6) of 67 rooms in facility. Findings include: Record review of facility policy titled, Resident Rights: Dignity and Respect, dated 2/12/24, revealed, To provide the kind of care to our residents that should maintain and enhance their dignity, individuality, and quality of life by the following treatment. a living environment that is safe, clean, and comfortable. During an initial observation on 1/6/25 at 12:10 PM, room A-12 was noted to be in disrepair and had multiple areas of the room that had paint missing on the walls. Several areas of the room were observed that included an area by door measuring approximately eight (8) inches x 6 inches, an area near the bathroom counter measuring approximately four (4) inches x five (5) inches, and other smaller areas scattered around the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and record review, the facility failed to accurately complete section A of the Minimum Data Set (MDS) for a resident with a serious mental illness for two (2) of 26 MDS reviewed. Resident #2 and #76 Findings Include: The facility provided a statement on letterhead dated 1/8/25 and signed by the Administrator that read, We follow the CMS (Centers for Medicare and Medicaid) RAI (Resident Assessment Instrument) version 3.0 for policy information regarding MDS (Minimum Data Set) accuracy. Resident #2 Record review of Resident #2's PASRR (Preadmission Screening and Resident Review) Summary Findings dated 6/25/24 revealed under, Mental Health: . The individual meets criteria for having a diagnosis of mental illness as defined by PASRR. Also revealed under, Axis I primary: Schizophrenia was listed. Record review of the admission MDS with an Assessment Reference Date (ARD) of 8/5/24 revealed under section A 1500, Is the resident considered by state level II PASRR process to have serious mental illness and /or intellectual disability or a related condition? No was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-09-07 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and facility policy review the facility failed to ensure food items in the refrigerator/freezer were labeled and dated or discarded by expiration date and failed to ensure a dietary cook was wearing a beard restraint while prepping foods, for one (1) of two (2) kitchen tours. Findings Include Record review of the facility policy titled, Food and Supply Storage with a revision date of 1/23 revealed Policies: All food, non-food items, and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . Procedures: . Cover, label and date unused portions and open packages .Discard food past the use-by or expiration date . Record review of facility policy titled, Uniform Dress Code with a revision date of 1/23, Policy #E006 revealed .Procedures: Associates Working with Food .Restrain all facial hair with a beard net/restraint . An observation and interview during the initial tour of the kitchen on 09/05/23 at 10:10 AM, revealed the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-07 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review and facility policy review, the facility failed to provide dignity to a resident with a urinary catheter bag for one (1) of six (6) residents with a urinary catheter. Resident #52 Findings Include: Review of the facility policy titled Resident Rights: Dignity and Respect with a revision date of July 2012 revealed under, Policy: It is the policy of (proper name of facility) that residents should be treated with dignity and respect. The facility provided documentation titled Facility Specific Handout that revealed under, Providing Excellent Resident Care: . 5. Catheters: Use privacy bag or pillowcase . An observation on 9/06/23 at 10:25 AM, revealed the resident lying in bed with a urinary catheter drainage bag containing light yellow urine that was uncovered and visible from the hallway. An observation and interview on 9/06/23 at 10:42 AM, with Registered Nurse (RN) # 2 confirmed that Resident #52 had a urinary drainage bag that was uncovered and in view from…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-07 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, and facility policy review, the facility failed to promptly address and provide a follow up to grievances for four (4) of 32 residents reviewed. Resident #45, Resident #47, Resident #62, and Resident #64. Findings Include Record review of facility policy titled, Resident Rights: Complaint/Grievance Policy and Procedure dated 10/17, revealed, Policy: To provide a timely mechanism for receiving, responding, resolving, and documenting the outcome of patient complaints and grievances that is in compliance with current Resident Rights guidelines. The policy also revealed, 5. Response to a grievance is expected to take place within five business days of receipt of grievance and acknowledged in writing appropriately to the resident council, resident, or his/her representative. Record review of facility policy titled, Electronic Device Guidelines, undated, revealed, The use of electronic devices and social media has become a part of many employees' daily lives, but…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-07 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, record review and facility policy review the facility failed to develop and implement a comprehensive care plan for a resident requiring nail care Resident #71 and for a resident with limited range of motion (ROM) Resident #26 and Resident #45 for three (3) of 23 resident care plans reviewed. Findings include: A record review of the facility Policy, Titled, Care Plan Policy with a revision date of October 2012, revealed, .Procedure .In accordance with each resident's plan of care, all services provided or arranged by the facility should meet professional standards of quality and should be provided by qualified persons. A record review of the facility handout titled Facility Specific Handout with no revision date revealed under the title Providing Excellent Resident Care . 6. Nail care: clean nails every shift/PRN (as needed) and file as needed. RN/LPN (Registered Nurse/Licensed Practical Nurse. Resident #71 A record review of Resident #71's Care plan,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review and facility policy review the facility failed to provide personal hygiene to a resident requiring assistance as evidenced by long dirty jagged nails for one (1) of 23 residents reviewed. Resident #71 Findings include: A record review of the facility policy titled, Nails, Care of with a revised date of 07/17, revealed under Policy .It is the policy of (facilities proper name) that nails should be properly cared for. A record review of the facility handout titled Facility Specific Handout revealed under the title Providing Excellent Resident Care . 6. Nail care: clean nails every shift/PRN (as needed) and file as needed. RN/LPN (Registered Nurse/Licensed Practical Nurse) Observations on 09/05/23 at 11:05 AM and 4:36 PM, of Resident #71 revealed bilateral fingernails were approximately one-half (1/2) inch long and jagged past the tips of his fingers with a brown substance underneath his fingernails. An observation on 09/06/23 at 10:00 AM, of Resident #71…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-07 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review and facility policy review, the facility failed to provide range of motion (ROM) exercise for a resident at risk for contractures Resident #45, and a splint for a resident with contractures Resident #26 for two (2) of 44 residents reviewed with limited ROM. Findings include: Record review of the facility policy titled Restorative Care Program with a revision date of 08/18 revealed under, Policy: It is the policy of (proper facility name) that residents' maximum functional potential and independent living should be promoted. Also revealed under, a. Range of Motion . These exercises should be planned, scheduled, and documented in the clinical record. Also revealed under, Splint or Brace Assistance: . 2) where staff have a scheduled program of applying and removing a splint or brace, assess the resident's skin and circulation under the device, and reposition the limb in correct alignment. These sessions are planned, scheduled, and documented in the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-07 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview and facility policy review the facility failed to safely secure medications as evidenced by an unlocked and unattended medication cart on one (1) of three (3) survey days. Findings include: Review of the facility policy titled, Medication Administration with a revision date of 03/18 revealed under Medication Administration . #4. Storage of medications and several other associated products should be secure, i.e., in a locked med room, in a locked drawer/cabinet, or under constant surveillance. Any product used in a therapeutic manner should be treated and administered as a medication . An observation and interview on 09/05/23 at 11:50 AM, revealed the medication cart on the B Hall was unlocked and unattended. This observation revealed Licensed Practical Nurse (LPN) #1 walked away from the medication cart and went two doors down to administer medications and left the medication cart unlocked and unattended. An interview with LPN #1 confirmed that the medication cart was unlocked and unattended. She stated that the purpose of locking the medication…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$8,788 in federal fines across 1 penalty.

  • $8,788 — penalty dated 2025-11-04

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to NORTH MISSISSIPPI HEALTH SERVICES — 2 facilities. Here is how its ratings compare with the chain’s average across all its homes:

RatingThis homeChain avg
Overall 2 of 52.5-0.5 vs chain
Health inspection 2 of 52.0≈ chain avg
Staffing 3 of 54.0-1.0 vs chain
Quality measures 4 of 54.0≈ chain avg
The other 1 home this chain runs (chain average 2.5★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
NORTH MISSISSIPPI MEDICAL CENTER, INC.Organization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 03/16/2009
NOBLES, SHARONIndividualCORPORATE OFFICER; ADP OF THE SNFsince 03/13/2017
TOPPIN, BRUCEIndividualCORPORATE OFFICER; ADP OF THE SNFsince 03/16/2009
BARRETT, DYLANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/21/2022
ARRIOLA, RAYMONDIndividualADP OF THE SNFsince 04/29/2025
SPEES, MICHAELIndividualADP OF THE SNFsince 02/01/2014

CMS files one row per role, so the 11 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.6M
Net patient revenuemost recent cost report
-8.5%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 78%Medicare 4%Other / private 18%

About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$308per resident / day
operating cost
$9,349per month
≈ monthly operating cost
$284per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MS

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Mississippi Medicaid page.

Typical monthly cost in Mississippi
$9,581/mo
Nursing home (semi-private)
$9,885/mo
Nursing home (private)
$4,369/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 255161. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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