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Jasper County Nh

15 A South Sixth Street, Bay Springs, MS 39422 · Government - County · 110 certified beds · (601) 764-2101 Medicaid only — no Medicare

Call the home — (601) 764-2101 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0605) — cited Oct 2025Resident-funds citation (F0565)1 actual-harm citation2 actual-harm citations CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0605), cited Oct 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0565)
  • it has 1 actual-harm citation
  • inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure 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) 4 of 5
Quality measuresSelf-reported by the facility 2 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Urgent care / clinic
20 S Sixth St · (601) 764-4494 · Call to confirm hours
Pharmacy
4 N 3rd St · (601) 764-2862 · Call to confirm hours
Grocery
9 Bay Ave · (601) 764-2164 · Call to confirm hours
Park
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 2 of 5
Long-stay residentspeople who live here 2 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 2 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 rating2★
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 increased16.4%20.5%15.4%typical
Long-stay residents who lose too much weight9.8%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder2.7%1.4%0.9%worse
Long-stay residents with a urinary tract infection4.4%2.5%2.0%worse
Long-stay residents with depressive symptoms0.0%1.6%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury3.8%3.1%3.3%worse
Long-stay residents whose ability to walk worsened12.7%19.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication26.2%23.8%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%97.0%95.3%typical
Long-stay residents with pressure ulcers7.1%6.3%4.7%worse
Long-stay residents with worsening bladder/bowel control17.0%20.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table27.9%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication13.6%2.5%1.4%worse
Short-stay residents rehospitalized after admission10.8%27.7%22.6%better
Short-stay residents with an outpatient ER visit5.4%15.5%12.0%better
Long-stay hospitalizations per 1,000 resident days1.772.431.67typical
Long-stay outpatient ER visits per 1,000 resident days1.572.861.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

§ 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.

0.29U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% 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 SNFnot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.

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

0.59
RN hours/ resident / day
1.17
LPN hours/ resident / day
2.82
Aide hours/ resident / day
4.57
Total nurse hours/ resident / day
0.23
RN hoursweekends
42.7%
Total nursing turnover
25.0%
RN turnover

How full it usually is: this home is certified for 110 beds and averages 100.5 residents a day — about 91% occupied, or roughly 10 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 4.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.82 is at or above 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 3.85 hrs/resident/day on weekends vs 4.86 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.73 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%.

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

9
deficiencies at the latest standard inspection (2025-10-09)
8
at the previous standard inspection (2024-11-07)

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.

24 citations, most serious first. The 13 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · G2025-10-09 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident was free from unnecessary medications when the resident received an antipsychotic medication without an appropriate diagnosis and without informed consent, which resulted in lethargy, weight loss, and poor meal intake for one (1) of five (5) residents reviewed for unnecessary medications. Resident #79.Findings include:A review of the facility's policy titled .Use of Psychotropic Medication(s), dated 9/17/25, revealed, .It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated.During an observation on 10/6/25 at 12:15 PM, Resident #79 was observed asleep in her wheelchair in the common area.On 10/8/25 at 1:05 PM, Resident #70 was observed asleep in her wheelchair and remained asleep until 5:15 PM.On 10/8/25 at 4:17 PM, during an interview with Certified Nurse Aide (CNA) #1, she explained that Resident #79 had good days and bad days, often refusing to eat on…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-01-02 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 interviews, record reviews, and facility policy review, the facility failed to ensure services provided met current professional standards when Licensed Practical Nurse (LPN) #1 prepared two (2) residents medications simultaneously and administered the wrong medications to Resident #1, resulting in the resident being admitted to the intensive care unit (ICU) of a local acute care hospital due to an adverse reaction for one (1) of four (4) sampled residents. Resident #1 Findings Included: A review of the facility policy titled Medication Set-Up and Administration, revised 5/31/2023, revealed, Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice .8. Identify residents by photo in the electronic medication administration record (EMAR). Record review of the facility's Incident Note revealed, 12/15/2024 22:56 (10:56 PM) Incident Note .@1930 (7:30 PM) arrived to station 4 and notified of cart nurse (LPN #1) medication error.…

    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 · Past Non-Compliance
  • Actual harm · G2025-01-02 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 interviews, record review, and facility policy review, the facility failed to prevent a significant medication error when Licensed Practical Nurse (LPN) #1 administered blood pressure medications to a resident that were prescribed for his roommate, resulting in Resident #1 being admitted to the intensive care unit (ICU) of a local acute care hospital due to an adverse reaction for one (1) of four (4) residents reviewed. Resident #1 Findings Included: Record review of the facility's policy titled Medication Set-Up and Administration, dated 5/31/23 revealed, .Policy .Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines .8. Identify residents by photo in the EMAR (electronic medication administration record) . Record review of the facility's Incident Note revealed, 12/15/2024 22:56 (10:56 PM) Incident Note .@1930 (7:30 PM) arrived to station 4 and notified of cart nurse (LPN #1)…

    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 · Past Non-Compliance
  • Potential for harm · Ecited before2025-10-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, record review, and facility policy review, the facility failed to follow infection prevention and control practices, as evidenced by failure to wear gloves during the administration of eye drops and by placing medication containers on contaminated surfaces without cleaning or using a barrier for two (2) of three (3) residents observed for medication administration (Residents #14 and #96). Findings include:A review of the facility's .Medication Administration Policy, dated 7/30/25, revealed, . Medications are administered by licensed nurses.as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .Resident #14A record review of the admission Record revealed the facility admitted Resident #14 on 11/14/22 with current diagnoses including Unspecified Glaucoma.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/28/25 revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-09 · 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 observation, staff interview, record review, and facility policy review, the facility failed to ensure a resident's right to privacy and dignity during medication administration when licensed nursing staff administered prescribed eye drops to a resident in the dining room while other residents were present, for one (1) of three (3) residents reviewed for medication administration, Resident #96.Findings include:A review of the facility's .Medication Administration Policy, dated 7/30/25, revealed, .Policy Explanation and Compliance Guidelines.7. Provide privacy.On 10/7/25 at 8:37 AM, during an observation, LPN #1 administered medications to Resident #96 while the resident was in the dining room. At the time of the observation, nine (9) other residents were also present in the dining room.On 10/7/25 at 8:45 AM, during an interview, LPN #1 stated she normally administered medications in the dining room for residents who were present there during the morning medication pass. She reported that Resident #96 had not expressed a problem with receiving medications in the dining room…

    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 · D2025-10-09 · 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, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) related to an insulin medication for Resident #2 and an anticoagulant medication for Resident #14 for two (2) of (21) sampled residents.Findings include: A review of the facility's policy, Assessment Frequency/Timeliness dated 10/1/23, revealed, The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI (Resident Assessment Instrument) Manual . Resident #2A record review of Drugs.com website revealed the drug classification for Trulicity is GLP-1 receptor agonists.A review of the admission Record revealed the facility admitted Resident #2 on 6/19/24 with current diagnoses including Type 2 Diabetes Mellitus with Diabetic Neuropathy. A record review of the Quarterly MDS with an ARD of 8/04/2025 revealed Section N, N0300. Insulin was marked as Resident #2 had received two (2) insulin injections in the seven (7) day look-back period.A record review of the Order Summary Report…

    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 · D2025-10-09 · 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, interviews, record review, and facility policy review, the facility failed to implement resident-specific care plan interventions when staff did not provide personal hygiene (shaving) as identified in the care plans (Residents #6 and #11), and failed to develop a care plan addressing triggers and interventions for a resident with Post-Traumatic Stress Disorder (PTSD) (Resident #2) for three (3) of (21) sampled residents.Findings include:A review of the facility's Care Plan Assessment (CAA) Care Planning Policy (undated), revealed, It is the policy of this facility that the CAA/Care Planning Process will be done as follows: Includes.Each triggered CAA will be assessed to facilitate a plan of care based on problems identified through the assessment process.Resident #2On [DATE] at 11:55 AM, during an interview with Resident#2 she confirmed she had the diagnosis of PTSD and reported it is related to her husband died due to a stab wound to his leg. He bled out and said he waited to tell her 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-09 · 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, interviews, record review, and facility policy review, the facility failed to provide shaving for residents who were dependent on staff for Activities of Daily Living (ADLs) for two (2) of (21) sampled residents, Residents #6 and #11.Findings include:A review of the facility's Shaving Policy, (undated) revealed, It is the policy of this facility that male residents will be shaved as follows: - Encouraged to be shaved daily and as needed .Resident #6A record review of the admission Record revealed the facility admitted Resident #6 on 2/13/23 with diagnoses including Alzheimer's Disease.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/9/25 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident's cognition was moderately impaired. Section GG revealed Resident #6 had limitations in range of motion in both lower extremities and was dependent on staff for bathing and personal hygiene.A record review of the facility's Bath Schedule - Group C revealed Resident #6…

    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 · D2025-10-09 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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 interviews and record review, the facility failed to ensure triggers and resident specific interventions were identified and initiated for a resident with Post Traumatic Stress Disorder (PTSD) for one (1) of (21) sampled residents. Resident #2.Findings include:A review of a written statement provided and signed by the Administrator revealed, (Proper Name) Nursing Home does not have a policy on Post-Traumatic Stress Disorder.A record review of the admission Record revealed the facility admitted Resident #2 on [DATE] with current diagnoses including Post-Traumatic Stress Disorder, Unspecified.A record review of the Order Summary Report revealed orders for .May consult (Proper Name) Health Services for Psych (Psychiatric).as needed, dated [DATE], and May have Psych consult as needed, dated [DATE].A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-09 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    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 maintain an accurate resident clinical record related to a physician's order for a resident hospital transfer for one (1) of (21) sampled residents. Resident #7Findings include: A review of the facility's Physician's Orders Policy, revised 8/29/17 revealed .Reminders.The nurse noting the order is responsible for.Transcribing the orders to the appropriate place. A record review of the facility's admission Record revealed the facility admitted Resident #7 on 4/23/2019 with current diagnoses including Type 2 Diabetes Mellitus A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/25/25 revealed Resident #7 was transferred from the facility due to a unplanned discharge to a Short-Term General hospital on 7/25/2025. A record review of Progress Notes revealed Resident #7 had a Transfer to Hospital Summary note, dated 7/25/2025, which indicated she had been sent to an acute hospital for further evaluation. A review of the clinical record for Resident #7…

    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 · Ecited before2024-11-07 · tag F0550 — failed to protect resident dignity and rights — pattern
    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 observation, record reviews, interviews, and facility policy review, the facility failed to treat residents in a dignified manner by posting clinical data in a resident room (Resident #85) and failing to knock before entering a resident's room (Resident #69) for two (2) of 21 sampled residents. Findings Include: A review of the facility's Dignity Policy, undated, revealed, .It is the policy of this facility to promote care for the residents .in a manner and environment that maintains or enhances each resident's dignity, with respect in full recognition of his or her individuality .Special Concerns .Respecting the resident's private space and property, knocking on doors and requesting permission to enter . Resident #69 On 11/5/23 at 12:10 PM, during an observation and interview with Licensed Practical Nurse (LPN) #2, Certified Nurse Aide (CNA) #2 entered Resident #69's room without knocking on the door, addressing the resident, or introducing herself and did not explain the purpose for her visit. CNA #2 placed the resident's meal tray on the bedside table, set it up for…

    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 · E2024-11-07 · tag F0565 — failed to support the resident council — pattern
    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

    Based on interviews, record review, and facility policy review, the facility failed to ensure grievances raised by resident council members were consistently resolved for six (6) of (12) months. Findings Include: A review of the facility's Grievance/Complaint Policy (undated) revealed It is the policy of this facility that a resident/responsible party/legal representative has the right to voice a grievance .All grievances should be directed/reported to Social Services . A review of the facility's Resident Council Policy (undated) revealed, It is the policy of this facility that residents have the right to form a Resident Council group to elect a governing body made up of fellow residents who preside over the resident council, conduct regularly scheduled meetings .Purpose .to identify problems within the nursing home, to help resolve the problems that have been identified . A record review of the resident council minutes revealed from 5/22/24 through 10/16/24, residents had recurring complaints regarding issues such as staff noise on the unit, staff clearing meal trays before…

    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 · Ecited before2024-11-07 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, record review and facility draft policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for one (1) of three (3) residents reviewed as high risk for acquiring multi-drug-resistant organisms (MDROs) Resident #69 and had the potential to affect six (6) residents identified as high risk for MDROs. Findings Include: Record review of the facility policy Draft Enhanced Barrier Precautions Policy dated reviewed 9/28/24 revealed This policy aims to mitigate the risk of transmission of Multidrug-Resistant Organisms (MDROs) within our facility by implementing Enhanced Barrier Precautions (EBP). This policy seeks to prevent the spread of MDRO's among residents and staff members by expanding the use of personal protective equipment (PPE) during high contact resident care activities for certain residents .Policy Explanation and Compliance Guidelines .4. Examples of indwelling medical devices for EBP should include but are not limited to .feeding tube . On 11/05/24 at 12:10 PM, during an observation, Licensed Practical Nurse (LPN…

    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
Show the remaining 11 citations
  • Potential for harm · D2024-11-07 · 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, interviews, record reviews, and facility policy review, the facility failed to maintain and provide a clean, sanitary, and home-like environment for one (1) of twenty-six (26) resident rooms on Unit 2. This affected Resident #2. Findings Include: A review of the facility's Environmental Policy (undated) revealed, .It is the policy of this facility to provide a safe, clean, comfortable, and homelike environment .Special Information - A determination of 'comfortable and homelike' should include whenever possible, the resident's or a representative of the resident's opinion of the living environment .'Environment' refers to any environment in the facility that is frequented by residents, including resident rooms, bathrooms . On 11/05/24 at 11:06 AM, during an observation and interview with Resident #2, the resident reported that her bathroom was not cleaned appropriately. A thick white substance (dust) was observed on the ceramic tile in the resident's bathroom and on the back of her recliner. During an interview on 11/07/24 at 11:00 AM, the housekeeper confirmed…

    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 · D2024-11-07 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be free from physical restraints by not identifying and documenting the use of a seatbelt as a restraint for one (1) of 21 sampled residents. Resident #44. Findings Include: A review of the facility's Restraint Policy dated 09/18/14 revealed, .It is the policy of this facility that restraints will be used as follows: Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body . On 11/04/24 at 12:07 PM, during an observation, Resident #44 was sitting in a wheelchair in the day room with a seatbelt attached across the waistline. When asked if she could remove the seatbelt, Resident #44 was unable to understand the request. At 1:20 PM on 11/05/24, during an interview with Certified Nurse Aide (CNA) #1, she reported that although Resident #44 understands some…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff, Resident Representative (RR) interview and record review, the facility failed to provide written notification to the resident or RR of a transfer to an acute care hospital for one (1) of (21) residents sampled. (Resident #7) Findings Include: A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/24 indicated Resident #7 was discharged to an acute hospital and it was anticipated she would return to the facility. On 11/06/24 at 8:38 AM, during an interview with the Director of Nursing (DON), she acknowledged that the facility did not provide written documentation to Resident #7's Representative (RR) to inform them of the resident's transfer to the hospital or the reason for the transfer. The DON confirmed that the facility calls the resident's RR by phone to inform them that the resident has been sent to the hospital. On 11/06/24 at 8:45 AM, during an interview with the RR, she stated that facility staff spoke with her in person regarding the resident being sent to the hospital and the reason for the hospitalization.…

    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 · D2024-11-07 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and facility policy review, the facility failed to obtain a Level II Preadmission Screening and Resident Review (PASARR) for a resident receiving psychotropic medications and diagnosed with a new mental health diagnosis for one (1) of one (1) resident reviewed for PASARR. (Resident #69) Findings Include: Record review of the Resident Assessment-Coordination with PASARR Program, undated, revealed Policy: This facility coordinates assessment with the preadmission screening and resident review (PASARR) under Medicaid to ensure that individual with a mental disorder, intellectual disability or related condition receives care and services in the most integrated setting appropriate to their needs .9.Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review . A record review of Resident #69's Pre-admission Screening (PAS), dated 03/25/22 revealed the Level II Referral…

    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 · D2024-11-07 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 and interviews, the facility failed to maintain an audible call light system for one (1) of (16) rooms observed on Unit 4 hall. room [ROOM NUMBER] Findings Include: On 11/04/24 at 11:12 AM, during an observation, the call light in room [ROOM NUMBER] was noted to be hanging from the outlet. The resident in the room activated the call light, but it did not illuminate above the door or sound. During an interview and observation on 11/04/24 at 11:15 AM, Housekeeper #3 attempted to activate the call light unsuccessfully and stated this was the first time she noticed the light not working, despite Resident #76 frequently using the call light for assistance. During an interview and observation on 11/04/24 at 11:20 AM, Licensed Practical Nurse (LPN) #3 also attempted to activate the call light in room [ROOM NUMBER] and confirmed it was not working properly. She stated she was unaware that the call light was not functioning. She explained that both residents in the room typically used the call light…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-23 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, record reviews, and facility policy review, the facility failed to transmit Minimum Data Set (MDS) Assessments by the target date, for seven (7) of 20 residents reviewed for MDS assessments. Resident #4, #12, #37, #40, #46, #49, and #59. Findings Include: Review of the Resident Assessment Instrument Policy (undated) revealed, It is the policy of this facility that the RAI (Resident Assessment Instrument) will be done as follows: According to the guideline specified by: State Department of Health, Division of Medicaid, Case Mix Trainers, Completed by Inter Disciplinary Team, Coordinated by the RN (Registered Nurse) . MDS Assessments will be submitted in timely manner within the 14 day timeframe . Record review of MDS Assessments revealed the following: 1. The yearly assessment for Resident #4 had a target date of 2/10/23 and was not transmitted until 3/17/23. 2. The quarterly assessment for Resident #12 had a target date of 1/30/23 and was not transmitted until 3/17/23. 3. The quarterly assessment for Resident #37 had a target date of 2/12/23 and 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-23 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 observation, interview, and facility policy review, the facility failed to discard expired food and failed to serve food in a sanitary manner related to staff touching a resident's food item for two (2) of five (5) kitchen and dining observations. Findings include: A review of the facility's policy Food Safety and Sanitation, undated, revealed . All local, state, and federal standards and regulations are followed in order to assure a safe and sanitary food service department. Procedure . 4. Food Storage . b . All leftovers are labeled, covered, and dated when stored. They are used within 72 hours (or discarded) . On 03/20/23 at 12:20 PM, during a kitchen observation, there were 24 hot dog buns and nine (9) hamburger buns wrapped in plastic wrap in a clear container. The buns had an open date of 3/07/23 and a use by date of 3/13/23. The buns were firm and hard when touched. On 03/20/23 at 12:45 PM, in an interview with the Dietary Manager, she stated food items are dated to ensure foods served are fresh and not expired because serving expired foods could cause the residents…

    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 · D2023-03-23 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and facility policy review, the facility failed to accommodate resident preferences by not allowing bedfast residents to receive showers as their preferred bathing method for two (2) of two (2) residents reviewed for preferences. (Resident #7 and Resident #41) This had the potential to affect (12) of (12) bedfast residents. Findings include: Record review of the facility's, Bed Bath Policy, undated, revealed, It is the policy of this facility that a bed bath will be given as follows: For any bed bound resident . Resident #7 During an interview on 3/22/23 at 4:25 PM, with Registered Nurse (RN) #1, she confirmed Resident #7 received bed baths. She explained the facility did not have the equipment for bed bound resident to receive showers, but they were given bed baths daily. During an interview on 3/22/23 at 4:30 PM, Resident #7's father complained that the resident only received a bed bath. He stated he was told by the facility that she could only get bed baths because she was bed bound and required a Hoyer (mechanical) lift. He explained that 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 · Dcited before2023-03-23 · 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 ensure a resident who was dependent on staff for personal hygiene received services related to nail care for one (1) of three (3) residents reviewed for Activities of Daily Living (ADLs). Resident #7 Findings include: Record review of the facility's, Nail Care Policy, undated, revealed, It is the policy of this facility that nail care will be done as follows: On a daily basis as a part of the resident's personal grooming, Provided to all residents requiring assistance with nail care .Includes: Cleaning fingernails and toenails (done daily and PRN [as needed]), Regular trimming of the nails (trimmed Q [every] 2 weeks and PRN), Filing to maintain a smooth edge . Resident #7 During an observation on 03/21/23 at 11:49 AM, Resident # 7 was in a Geri chair. Her left hand was contracted and pressed tightly against her body in her chest area and her left thumb nail was one and one-half (1½) inches in thickness, jagged, and had a dark discoloration. During an interview on 3/22/23 at 4:15 PM,…

    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
  • No harm found · B2025-10-09 · tag F0732 — pattern
    Post nurse staffing information every day.
    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 ensure nurse staffing information was posted in a location daily that was visible to residents and the public for two (2) of four (4) survey days.Findings include:A review of the facility's Posting Daily Staffing Information Policy (undated) revealed, It is the policy of this facility that Nurse Staffing information will be posted as follows.The information will be posted daily.This form will be posted in the foyer of the building.On 10/6/25 at 11:05 AM, during an observation of the common areas, including the facility's foyer, and surrounding the nursing stations on Unit 200, Unit 300, and Unit 400, there was no posted nurse staffing information visible.On 10/7/25 at 2:09 PM, during an observation of the common areas, including the facility's foyer, and surrounding the nursing stations on Unit 200, Unit 300, and Unit 400, there was no posted nurse staffing information visible.On 10/7/25 at 3:25 PM, during an interview with the Assistant Director of Nursing (ADON), she explained that the daily…

    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
  • No harm found · C2023-03-23 · tag F0888 — widespread
    Ensure staff are vaccinated for COVID-19
    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 ensure policies and procedures addressed a process for ensuring the implementation of additional precautions intended to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated for COVID-19. This had the potential to affect 95 of 95 residents in the facility. Findings include: A review of the facility's policy, COVID-19 Vaccination Policy, revised 10/11/22, revealed there were no additional precautions implemented to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated. On 3/22/23 at 11:57 AM, in an interview with the Infection Preventionist, she stated that the staff who are not vaccinated and have been granted an exemption are not required to do anything different than vaccinated staff and that all staff are required to wear a surgical mask. On 3/22/23 at 1:01 PM, in an interview with the Office [NAME] Clerk, she confirmed that she was not vaccinated and that she had a medical exemption. She stated 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.

    Infection Control 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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in MS

Paying with Medicaid

CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. 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 25A178. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-10-09, 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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