The Pillars Of Biloxi

Location & what’s nearby

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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

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.

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.

46.5% 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 68 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 13.0% 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 23 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 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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.

Staffing

How full it usually is: this home is certified for 180 beds and averages 142.9 residents a day — about 79% occupied, or roughly 37 beds typically open. It usually has some room. 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 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 3.16 hrs/resident/day on weekends vs 3.58 on weekdays — 12% thinner on weekends. RN hours go from 0.50 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Deficiencies are fewer than at the previous inspection — improving. 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.

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.

42 citations, most serious first. The 15 most serious are shown; the remaining 27 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-04-03 · 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, interviews, record review, and facility policy review, the facility failed to provide adequate supervision and ensure environmental safety to prevent Resident #1, a vulnerable resident, from exiting the facility unnoticed and unsupervised for one (1) of three (3) residents reviewed. Resident #1 On 3/23/25, Resident #1, who had a Brief Interview for Mental Status (BIMS) score of eight (8), physically pushed out and removed the window screen in his room and exited the building. Resident #1 exited the facility unnoticed and was last seen inside the facility at 6:00 AM by a Certified Nursing Assistant (CNA) and was found at 6:30 AM by facility staff (Dietary Cook) who was reporting to work. The resident was observed by the [NAME] walking around side of the building and was approximately 130 steps away from the building. Resident #1 was wearing shorts only and no shoes. The facility's failure to provide supervision and ensure environmental safety put Resident #1 and other vulnerable residents at risk for serious injury, serious harm, serious impairment, or death.…

  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 · Past Non-Compliance
• Immediate jeopardy · Jcited before2024-08-14 · 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 interviews, record reviews, and facility policy review, the facility failed to implement care plan interventions related to wandering/elopement risk for one (1) of four (4) resident care plans reviewed. Resident #1. The facility's failure to implement care plan interventions resulted in Resident #1 exiting the facility unsupervised and unnoticed by facility staff. Facility staff took Resident #1 to the therapy gym at approximately 9:50 AM on 8/8/24. She was determined to be missing at 9:55 AM and was found at 10:23 AM, about one (1) mile from the facility. During the investigation, the SA identified an Immediate Jeopardy (IJ) which began on 8/8/24 and existed at 42 CFR: 483.21(b) Comprehensive Care Plans - F656 - Scope and Severity J. This situation placed Resident #1 and other residents at risk for wandering and elopement, at risk for likelihood of serious injury, serious harm, serious impairment, or death. The SA notified the facility's Administrator of the IJ on 8/13/24 at 3:00 PM and provided the Administrator with the IJ template. Based on the facility's implementation…

  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
• Immediate jeopardy · Jcited before2024-08-14 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, facility policy reviews, and the facility's investigation, the facility failed to provide adequate supervision to prevent Resident #1, who was identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. The facility's failure to provide supervision resulted in Resident #1 exiting the facility unsupervised and unnoticed by facility staff. Resident #1 was brought to the therapy gym at approximately 9:50 AM on 8/8/24 and left unattended. She was determined to be missing at 9:55 AM and was found at 10:23 AM, about one (1) mile from the facility. During the investigation, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 8/8/24 and existed at 42 CFR: 483.25 (d)(1)(2)- Free of Accidents Hazards/Supervision/Devices (F689) - Scope and Severity J. This situation placed Resident #1 and other residents at risk for wandering and elopement, likely for serious…

  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 · Past Non-Compliance
• Actual harm · Gcited before2025-03-21 · 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 interviews, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions for a resident who was identified as a fall risk, resulting in a fall that caused the resident to sustain a mildly displaced fracture of the proximal right humerus, for one (1) out of three (3) sampled residents. Resident #1. Findings include: A review of the facility's Care Plans, Comprehensive Person-Centered, reviewed 10/2022, revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas . A record review of the care plan revealed: .Date Initiated: 09/22/2015: Focus: Resident has self-care deficit .Interventions/Tasks: Transfer: Extensive, (X2) times two (2) Assist (w) with/sit to stand lift . Date initiated: 03/21/2023.…

  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 · Gcited before2025-03-21 · 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 interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent Resident #1, who was identified as a fall risk, from falling and causing the resident to sustain a mildly displaced fracture of the proximal right humerus for one (1) out of three (3) sampled residents, Resident #1. Findings include: A review of the facility's Safety and Supervision of Residents, reviewed 8/2023, revealed: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The record review of the facility investigation revealed Resident #1 had a witnessed fall on 2/13/25 at 6:49 AM. Certified Nurse Assistant (CNA) #1 reported that during the transfer of the resident from her bed to the wheelchair, the resident slipped, and CNA #1 lowered the resident to the floor. The facility sent the resident to the hospital for evaluation and treatment due to bruising and swelling to her right hand. The resident's x-rays showed a mildly…

  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 · Past Non-Compliance
• Potential for harm · E2026-02-24 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure residents received care and services in accordance with physician orders and professional standards of nursing practice for two (2) of three (3) residents reviewed, as evidenced by the facility did not discontinue narcotic medication as ordered and continued administration for four (4) days after discontinuation for Resident #2 and did not timely implement a newly ordered antibiotic following hospital return for Resident #1, resulting in a five (5) day delay in treatment for a urinary tract infection (UTI). Findings include: A review of the facility's Physician Order Policy, with a revision date of 1/20/2026 revealed .To ensure that residents' medication and treatments are ordered by a licensed physician or other licensed health care professional as permitted by state law. Procedure: Physician orders are carried out.Physician orders are to be recorded in the medical record for each resident.Each order should have 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 · D2026-02-24 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  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 interview, record review, and facility policy review, the facility failed to ensure nursing services were provided by qualified and licensed personnel when a graduate practical nurse (GPN) continued to function in the capacity of a licensed nurse for approximately five and one-half (5 1/2) days after receiving notification of failure of the National Council Licensure Examination (NCLEX) nursing exam for one (1) of three (3) facility nursing staff reviewed.Findings include: A review of the facility's policy Compliance and Ethics - Risk Areas for Fraud and Abuse, revised [DATE], revealed .Resident Quality of Care.2. A. Sufficient staffing - staffing is provided in sufficient numbers and with staff who have appropriate clinical training, licensure and/or expertise to meet the needs of residents. A record review Board of Nursing License Verification for GPN #1 revealed she had a License Type of LPN (License Practical Nurse) Temporary Permit that was issued on [DATE] and expired on [DATE]. A record review 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-08-21 · tag F0880 — failed to prevent and control infections — widespread
  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, record review and facility policy review, the facility failed to prevent the possible spread of infection, as evidenced by, failure to follow proper hand hygiene for Resident #26 and by placing soiled linen directly onto the floor for two (2) of four (4) days of survey.Findings include:A review of the facility's policy, Handwashing/Hand Hygiene, revised June 2010, revealed . This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water . n. Before and after assisting a resident with toileting . r. after handling soiled or used linens .A review of the facility's policy, Infection Control Program, reviewed 7/16/22, revealed,…

  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 · Ecited before2025-08-21 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  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, and record review, the facility failed to provide Activities of Daily Living (ADL) care to ensure a resident was kept clean after episodes of incontinence, as evidenced by staff requiring multiple wipes to remove dark residue from the groin area during incontinent care for one (1) of 29 sampled residents, Resident #74.Findings include: On 8/19/25 at 3:35 PM, during an observation and interview, Certified Nurse Aide (CNA) #3, reported that Resident #74 was always incontinent of bowel and bladder and dependent on staff for ADL care, including personal hygiene. During incontinence care with CNAs #2 and #3, Resident #74's groin area required extensive cleaning, with multiple wipes showing brown and black discoloration before the skin was clean. CNA #3 confirmed this was not bowel movement but an accumulation of dirt and residue, commenting the resident had not been adequately cleaned prior to their providing this care. On 8/19/25 at 4:00 PM, during an interview, the Director of Nursing (DON) reported she expected all residents to be properly cleaned…

  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 · Ecited before2025-08-21 · 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 ensure food items were properly stored, dated, and labeled in the dry goods room, freezer, and cooler for one (1) of two (2) kitchen observations. Findings include:A review of the facility's policy, Food Storage, dated 8/18/2011, revealed . It is the policy of this facility that food storage areas be maintained in a clean, safe, and sanitary manner. Procedure.2. All food not requiring refrigeration shall be stored above the floor . 8. All food stored in refrigerators and freezers that have been opened, will be covered and labeled with the date and name of the food . 11. All condiments that have been opened should be refrigerated and discarded after 30 days .On 8/18/25 at 9:25 AM, during an observation of the kitchen and interview with the Dietary Manager (DM), in the dry goods room, a broken scoop was stored inside the cornmeal, plastic cups were stored directly on the floor, a 16- pound container of cream cheese icing was observed with no opened date and the lid not secured, and an opened bag 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-21 · 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, interview, record review, and facility policy review, the facility failed to respect a resident's privacy during incontinent care (Resident #26) for one (1) of four (4) days of survey. Findings include:A review of the facility's policy titled, Dignity, revised 7/24/23, revealed, .Each resident shall be cared for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation 1. Residents are treated with dignity and respect at all times.11. Staff promote, maintain, and protect residents' privacy, including bodily privacy during assistance with personal care and treatment procedures.On 8/18/25 at 10:06 AM, during an observation while walking in the hallway with the Licensed Social Worker (LSW), Registered Nurse (RN) #2 was observed providing incontinent care for Resident #26 with the resident's door open. Resident #26's buttocks and genital area were exposed, and privacy was not maintained during the provision of care.On 8/18/25 at 10:09 AM,…

  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 · D2025-08-21 · tag F0585 — failed to handle grievances — isolated
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, interviews, and facility policy review, the facility failed to resolve a grievance in a timely manner for one (1) of (29) sampled residents (Resident #59). Specifically, the facility failed to replace a broken tablet reported on 5/29/25 until nearly three (3) months later, which did not ensure timely grievance resolution in accordance with facility policy.Findings include:A review of the facility's policy, Grievances, Complaints, Recording and Investigating, dated 7/24/23, revealed, .All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance.Policy Interpretation and Implementation.7. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation.within 5 working days of the filing of the grievance or complaint .On 8/18/25 at 11:14 AM, during an interview, Resident #59 stated a staff member knocked her tablet off of a surface and broke it. She stated the facility was to replace the device, but nothing had been done.A record review 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-21 · 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 staff interview, record review, and facility policy review, the facility failed to ensure antipsychotic medications were prescribed for residents with appropriate, clinically documented diagnoses for one (1) of six (6) residents reviewed for unnecessary medications. Resident #157Findings include: A review of the facility's policy, Antipsychotic Medication Use, revised 10/2022, revealed, Policy Interpretation and Implementation 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.A record review of the admission Record revealed the facility admitted Resident #157 on 9/20/24 with diagnoses including Major Depressive Disorder, Single Episode, Unspecified.A record review of the Discharge Summary from an acute care hospital, dated 9/20/24, revealed Resident #157's Problem List/Discharge Diagnosis included Hemorrhagic Cerebrovascular Accident, Disorientation, Pulmonary Embolism, Acute Kidney Injury, and Wheezing.A record review of the Diagnosis Report revealed Resident #157 had a diagnosis…

  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 · D2025-08-21 · 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

  Based on record review, staff interview, and facility policy review, the facility failed to ensure physician orders were followed for obtaining a Hemoglobin (Hbg) A1C (a blood test that measures average blood glucose levels over the past 2-3 months) as ordered for one (1) of six (6) residents reviewed for unnecessary medications. Resident #12.Findings include:A review of the facility's policy Physician's Orders dated 4/13/21 revealed, . Physician's orders are carried out unless the nurse or other licensed personnel believe the order to be inaccurate .A record review of the admission Record revealed the facility admitted Resident #12 on 4/25/18 with diagnoses including Diabetes Mellitus.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/1/25 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) Summary Score of 13, which indicated she was cognitively intact. A record review of the Order Summary Report with active orders as of 8/21/25 revealed Resident #12 had a Physician's Order, dated 10/23/24 for a (Hgb)A1C every six…

  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 · D2025-08-21 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  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's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to ensure residents received proper hygiene care for residents dependent on staff and failed to ensure the proper storage of food during an annual recertification survey on 04/04/2024 and was cited again for the same deficiencies during the current recertification survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for two (2) of eight (8) deficiencies cited. F677 and F812.Findings Include:A review of the facility's policy, Quality Assessment and Performance Improvement (undated), revealed . The facility will implement and maintain a Quality Assessment and Performance Improvement program. Overview: The Quality Assurance and Performance Improvement (QAPI) committee will implement a process that is ongoing, multi-level, and facility wide . 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.

  Administration 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.

Fines & penalties

$47,692 in federal fines across 4 penalties.

• $22,320 — penalty dated 2025-04-03
• $8,607 — penalty dated 2025-03-21
• $8,608 — penalty dated 2025-03-21
• $8,157 — penalty dated 2024-08-14

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 COMMUNITY ELDERCARE SERVICES — 17 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

CMS files one row per role, so the 9 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners 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.

About 87% 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. This home reported $3.2M paid to related parties — landlords or management companies under common ownership — equal to about 22% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 2024. 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

Straight from this home’s Medicare cost report (CMS, FY2024). 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