Brandon Community Care Center

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.

37.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 201 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 38.0% 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 50 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 0.11 therapist hours per resident per day in 2026Q1 — more than 7% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% 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.

Staffing

How full it usually is: this home is certified for 230 beds and averages 188.8 residents a day — about 82% occupied, or roughly 41 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 4.58 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.27 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.91 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 4.00 hrs/resident/day on weekends vs 4.82 on weekdays — 17% thinner on weekends. RN hours go from 0.30 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% is well above the national median of 45%. 4 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.

43 citations, most serious first. The 21 most serious are shown; the remaining 22 are one tap away and print in full.

• Immediate jeopardy · J2025-05-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  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, and record review the facility failed to protect the residents' right to be free from neglect by not ensuring staff implemented measures to mitigate the risk to prevent elopement for one (1) of six (6) sampled residents, Resident #5. On 5/01/25 at approximately 3:00 PM, the facility failed to prevent Resident #5, a resident who had recently exhibited new exit-seeking behaviors from exiting the facility unnoticed and unsupervised. The facility was unaware of Resident #5's whereabouts for approximately fifteen (15) minutes until a staff member went to his car on break and located her sitting in the passenger seat of his car with the windows up in an unshaded parking space approximately thirty-five yards from the facility entrance at approximately 3:15 PM. The parked car was in front of a sidewalk that led to a busy four-lane boulevard with no barrier or crosswalk. The facility failure to ensure Resident #5 was adequately supervised to ensure she did not exit the facility…

  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
• Immediate jeopardy · Jcited before2025-05-12 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and interviews it was determined that the facility failed to ensure that allegations of neglect and incident of elopement were reported to the appropriate agencies, including State Agency, in accordance with State law through established procedures for one (1) of six (6) sampled residents, Resident #5. On 5/01/25 the facility failed to report to the required agencies an allegation of resident neglect related to lack of adequate supervision resulting in the elopement of Resident #5. On 5/01/25 at approximately 3:00 PM, Resident #5, who had recently exhibited new exit-seeking behaviors, exited the facility unnoticed and unsupervised. The facility was unaware of Resident #5's whereabouts for approximately fifteen (15) minutes until a staff member went to his car on break and located her sitting in the passenger seat of his car with the windows up in an unshaded parking space approximately thirty-five yards from the facility entrance at approximately 3:15 PM. The parked car 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-05-12 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review and interviews it was determined that the facility failed to initiate a thorough investigation of an allegation of neglect and incident of elopement for one (1) of six (6) sampled residents, Resident #5. On 5/01/25 the facility failed to initiate an investigation of resident neglect related to lack of adequate supervision resulting in the elopement of Resident #5. Resident #5 was out of the facility unsupervised in the parking lot of the facility at shift change and got into a car in front of a sidewalk that led to a busy four-lane boulevard with no barrier or crosswalk. This car belonged to a staff member who found her in his car around 3:15 PM and escorted her back into the facility. The facility's failure to conduct a thorough investigation of the elopement of Resident #5 on 5/1/25 placed this resident, and other residents at risk for wandering and elopement, in a situation that was likely to cause serious injury, harm, impairment, or death. The State Agency (SA)…

  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
• Immediate jeopardy · Jcited before2025-05-12 · 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 interviews, policy review and record review it was determined that the facility failed to develop a comprehensive care plan for one (2) of six (6) sampled residents, Resident #5 and Resident #6 On 5/01/25, Resident #5 with documented new wandering and exit seeking behaviors for at least a week eloped from the facility unnoticed and was outside unsupervised for approximately fifteen minutes. Documentation of the resident's change of behavior, including wandering had been reported to her primary healthcare provider with new orders noted for urinalysis to check for urinary tract infection, but the facility failed to identify exit seeking and elopement risk or develop her care plan to provide adequate supervision to prevent elopement. While Resident #5 was out of the facility unsupervised in the parking lot of the facility at shift change she got into a person's car unknown to her in front of a sidewalk that led to a busy four-lane boulevard with no barrier or crosswalk. The facility's failure to identify…

  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
• Immediate jeopardy · Jcited before2025-05-12 · 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 observation, interviews, record review and facility policy review, the facility failed to provide adequate supervision and a secure environment to prevent the elopement of one (1) of six (6) sampled residents, Resident #5. On 5/01/25 at approximately 3:00 PM Resident #5 who had documented new wandering and exit seeking behaviors for at least a week exited the facility unnoticed and was outside unsupervised for approximately fifteen minutes until a staff member located the resident sitting in his unlocked car in an unshaded parking space approximately thirty-five feet from the facility entrance with windows up. The car was in front of a sidewalk that led to a busy four-lane boulevard with no barrier or crosswalk. Documentation of the resident's change of behavior, including wandering had been reported to her primary healthcare provider with new orders noted for a urinalysis to check for urinary tract infection, but the facility failed to identify exit seeking and elopement risk or provide adequate…

  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
• Immediate jeopardy · Jcited before2025-04-01 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan intervention related to the removal of a pressure dressing from a dialysis access site for one (1) of four (4) sampled residents. Resident #4. Findings included: A review of the facility's policy, Comprehensive Person-Centered Care Plans, dated 1/2025 revealed, .Each resident will have a person-centered plan of care to identify problems, needs strengths, preferences, and goals that will identify how the interdisciplinary team will provide care .6 Assigned disciplines will be identified to carry out the intervention . A record review of the Care Plan Report for Resident #4 revealed Focus (Proper Name) is at risk for complications .receives hemodialysis .Interventions .Remove pressure dressing four hours post dialysis unless specified by dialysis communication sheet . The intervention was dated 10/15/24. The assigned discipline was listed as Licensed Practical Nurse/Registered Nurse (LPN/RN). On 04/01/25 at 11:41 AM, during an observation with the Unit…

  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
• Actual harm · Gcited before2026-01-12 · 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 observation, interview, record review and facility policy review the facility failed to ensure the resident environment remained as free as possible from accident hazards and that each resident received adequate supervision and assistance to prevent accidents for one (1) of four (4) sampled residents reviewed for falls. Resident # 1. Findings include:Record review of the facility policy Safety and Supervision of Residents, undated, revealed, Policy Statement: 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.Record review of the facility policy Homelike Environment undated, revealed, Policy Statement: Residents are provided a safe.homelike environment.Record review of the Facility Self-Reported Incident for Resident #1 dated 12/26/25, revealed that Resident #1 had a fall in her room. Staff heard the resident crying and entered the room and found the resident lying face…

  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
• Actual harm · Gcited before2025-04-22 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and facility policy review, the facility failed to implement the resident's care plan interventions related to daily skin and foot assessments for one (1) of four (4) residents reviewed for care planning, Resident #1, which resulted in the facility not identifying or addressing developing wounds on the resident's foot, which remained untreated by facility staff for five (5) days after being discovered and treated at the dialysis center. Findings include: Record review of facility Comprehensive Person-Centered Care Plan policy dated 01/2025 revealed .Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences and goals that will identify how the interdisciplinary team will provide care .Procedure .6. Staff approaches are to be developed for each problem/strength/need .Assigned disciplines will be identified to carry out the intervention . A record review of the Care Plan Report for Resident #1 revealed a Focus of (Proper Name) has a dx (diagnosis) of Diabetes Mellitus with interventions…

  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
• Actual harm · Gcited before2025-04-22 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and facility policy review, the facility failed to provide necessary care and services and respond appropriately to changes in a resident's condition for one (1) of four (4) sampled residents (Resident #1), when wounds were identified and treated by the dialysis clinic on 4/16/25 and the facility was notified, but failed to assess or initiate treatment until 4/21/25, resulting in a delay in care and placing the resident at risk for a worsening wound condition and infection. Findings include: A review of the facility's policy, Weekly Skin Audit, dated 11/17, revealed, .A skin audit will be documented on residents weekly. Any identified skin conditions will be documented and treatment initiated .Procedure: 1. Every resident will have a head-to-toe skin evaluation performed and documented on a weekly basis. The evaluation will be documented electronically or on the weekly skin audit form . A review of the facility's policy, Preventative Skin Care, dated 01/15, revealed: It is the practice of this facility to provide routine preventive…

  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
• Actual harm · Gcited before2025-03-06 · 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, interview, record review, and policy review, the facility failed to develop and implement care plans for two (2) of eight (8) residents reviewed, Resident #5 and Resident #6. Findings Included: Policy review of the facility policy titled COMPREHENSIVE PERSON-CENTERED CARE PLANS dated 8/11 (August 2011) revealed POLICY: Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care . Resident #5 Record review of the comprehensive care plan revealed there was not a care plan developed related to catheter care for Resident #5. Record review of the comprehensive care plan revealed I am at risk for UTI's (urinary tract infections) and skin breakdown r/t (related to) bladder incontinence. Date Initiated 1/24/25 revealed there were no interventions that addressed the presence of an indwelling urinary catheter. Record review of comprehensive care plan included a new care plan…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and facility policy review, the facility failed to meet current professional standards of care as evidenced by no physician order written for a resident who had an indwelling foley catheter for one (1) of eight (8) residents reviewed. Resident #5. Findings Included: Policy review of the facility policy titled PHYSICIAN ORDERS dated 1/25 (January 2025) revealed Orders received from a physician must be written on a hard script and signed by a physician. RESPONSIBILITY: All Licensed Nursing Personnel . During an observation on 3/04/25 at 5:50 PM, in the Unit 2 Dining Room revealed Resident #5 was seated in a wheelchair with a urine collection bag beneath the wheelchair, uncovered, with approximately eighty (80) milliliters of golden yellow urine visible in the collection bag. During an observation and interview on 3/06/25 at 11:20 AM, the Administrator confirmed the resident did not have a privacy/dignity cover on his urine collection bag for his urinary catheter. During an interview on 3/06/25 at 11:35 AM, 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-18 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, record review and facility policy review, the facility failed to report allegations of abuse for one (1) of three (3) residents reviewed. Resident #1Findings include: A record review of the facility's Abuse Prevention policy with a revision date of 1/25 revealed alleged violations involving abuse, neglect. are reported immediately, but not later than 2 hours after the allegation is made.On 10/2/25 at 11:15 AM in an interview with the Director of Nursing (DON) she stated that on 9/7/25 Certified Nursing Assistant (CNA) #2 told her that CNA #1 asked for help giving Resident #1 a bed bath. She stated the resident is blind and deaf. She stated they communicate by writing simple words in the resident hands with their fingers to let her know what they are doing. CNA #1 tried to sit the resident up on the side of the bed and the resident's foot was stuck in the bedrail. The resident sleeps at the foot of the bed. She stated CNA #1 did not see that the resident's right foot was stuck in the bedrail. CNA #2 saw it and told CNA #1 to stop. She stated 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-31 · 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 ensure staff honored a resident's preference to be put back to bed after therapy, resulting in the resident experiencing pain and emotional distress for one (1) of (35) sampled residents. Resident #216.Findings include:A review of the facility's policy, Resident [NAME] of Rights, no date, A .1 .15. Self-determination, which the facility must promote and facilitate through support of resident choice, consistent with his or her interest, assessment and plan of care and make other choices about aspect of his or life in the facility that are significant to the resident. Including but not limited to: activities, healthcare schedules (including sleeping, waking, bathing and eating times) and how she or he spends time .On 7/28/25 at 2:34 PM, Resident #216 shared that she typically attends therapy around 8:00 AM and finishes by 10:30 AM or 11:00 AM, after which therapy staff assist her in returning to her room. She reported that after therapy, she requested her assigned Certified Nursing Assistant (CNA) to…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-31 · 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, interview, record review and facility policy review, the facility failed to ensure that residents were transferred in a manner that could prevent accidents and potential injury for one (1) of (3) residents reviewed for accident hazards and safety. Resident #11.Findings included:Record review of facility policy titled Accident and Incident Documentation and Investigation Resident Incident History 7/18 revealed .Accidents and incidents will be analyzed for trends or patterns to enable the facility to enhance preventive measures to reduce the occurrence of incidents.On 7/30/25 at 1:15 PM, during an observation, Certified Nurse Aide (CNA) #6 was observed transporting Resident #11 from her room to the day room on the 400-hall using a wooden chair with no wheels. CNA #6 was seen pushing the resident from behind, with no method to stabilize the chair or catch the resident if she were to fall. Resident #11 typically sat in a rolling padded chair to support her trunk. By the end of the transport, Resident #11 had slid dangerously low in the wooden chair after being…

  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 · D2025-07-31 · tag F0800 — isolated
  Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, facility policy review and record review, the facility failed to provide a diet taking into consideration preferences of the resident for one (1) of 35 sampled residents. Resident #42Findings include:Record review of the facility policy revealed residents have a right to reside and receive services in the facility with reasonable accommodation of resident's preferences except when to do so would endanger the health or safety of the resident or other residents.During an observation on 07/29/2025 at 12:27 PM, Resident 42 was served a tray consisting of turkey, dressing, and a sweet potato. During an interview on 7/29/25 at 12:27 PM, Resident #42, asked CNA#4 to exchange her meal for a turkey sandwich. CNA #4 went to the kitchen and brought back a tray consisting of a piece of ham, broccoli and cheese and mandarin fruit cup and black-eyed peas. She stated that she was told by kitchen staff that they were out of sandwiches but would send this instead since it was the alternative.…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-31 · tag F0812 — failed to store, cook, and serve food safely — isolated
  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 practice hand hygiene in accordance with professional standards for food services as evidenced by the District Dietary Manager (DDM) placing her fingers in food on the food line for one (1) of three (3) kitchen observations. Findings include:Record review of the facility policy, Proper Hand Washing and Glove Use, 2016, revealed, All employees will use proper hand washing procedures and glove usage in accordance with State and Federal Sanitation Guidelines.Procedures.5.Gloves are to be used whenever direct food contact is required.On 7/30/25 at 11:11AM, during an observation and interview with kitchen staff the District Dietary Manager (DDM) used her bare finger to poke holes in the aluminum foil which covered the pans sitting on the hot food line and peel it back to expose the food. During the tray preparation the DDM was observed holding plates in such a way as to allow rolls to touch her bare hands at the thumb. In an interview with DDM, she failed to acknowledge the need for glove use during tray…

  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 · D2025-05-12 · tag F0691 — failed to provide colostomy / ostomy care — isolated
  Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
  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 provide appropriate care and services for Resident #6's nephrostomy tube. Specifically, the facility did not perform or document any nephrostomy tube dressing changes or flushes since admission, creating a potential for infection due to improper device care. This deficient practice affected Resident #6, one (1) of two (2) nephrostomy appliances in the building. Findings include: Record review of facility policy Weekly Skin Audit Policy: A Skin audit will be documented on residents weekly. Any identified skin conditions will be documented and treatment initiated. Responsibility director of nursing, licensed nurses, medical records. Procedure: 1. Every resident will have a head-to-toe skin evaluation performed and documented on a weekly basis, the evaluation will be documented electronically or on a weekly scan audit form. 5. Treatment will be initiated per the physician's orders. Record review of the Mississippi Attorney General…

  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 · D2025-04-01 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  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 timely removal of a pressure dressing from a dialysis access site for one (1) of one (1) resident reviewed for dialysis services. Resident #4. Findings included: A review of the facility's Dialysis Information Update Transfer Policy, dated February 2019, revealed, Policy: A 'Dialysis Information Update Transfer form' is completed each time a resident receives outpatient dialysis. This ensures enhanced communication between the two facilities .Procedure .3. The bottom section of the form is completed by personnel responsible for the resident at the dialysis facility and returned to the nursing home with the resident .5. As applicable, any instructions related to the resident care received from the dialysis unit should be relayed to the appropriate facility staff .and followed up as indicated. A record review of the Order Summary Report revealed Resident #4 had a Physician's Order, dated 8/1/2024 Remove pressure dressing 6 hours to left forearm dialysis shunt site after returning…

  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 · D2025-03-06 · 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 ensure residents were treated in a dignified manner when Resident #5's urinary catheter bag was left uncovered with urine visible in a public common area for one (1) of eight (8) residents reviewed. Resident #5 Findings Included: Policy review of the facility-provided Resident [NAME] of Rights with Review Date 1/15 (January 2015) revealed the document stated, It is the objective of the Facility to herein forth the rights of Residents so as to assure the protection and preservation of dignity . Facility Residents shall have the right to: 1. Privacy in treatment and personal care .26. Treated with consideration, respect, and full recognition of his/her dignity and individuality. Observation on 3/04/25 at 5:50 PM, in the Unit 2 Dining Room revealed Resident #5 was seated in a wheelchair with a urine collection bag beneath the wheelchair, uncovered, with approximately eighty (80) milliliters of golden yellow urine visible in the collection bag. Observation and interview on 3/06/25 at 11:20…

  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 · D2025-03-06 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
  Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, facility policy review, and interviews, the facility failed to provide necessary care for hygiene, bathing, and grooming for two (2) of eight (8) sampled residents, Resident #4 and Resident #6. Findings Included: Record review of the facility policy titled SHAVING-MALE AND FEMALE dated 8/11 (August 2011) revealed the policy stated, POLICY: Residents will be free of facial hairs - both male and female. If the resident is alert and oriented and requests not to be shaved, this will be noted in the Care Plan. RESPONSIBILITY: All Nursing Assistants monitored by Charge Nurse. Record review of the facility policy titled BATH/SHOWER-DEPENDENT dated 8/11 (August 2011) revealed, POLICY: A bath (shower/tub) for cleanliness and comfort is scheduled at least weekly for each resident. RESPONSIBILITY: Nursing Assistants or Licensed Nurses monitored by Charge Nurse . Resident #4 On 3/04/25 at 3:10 PM, observation revealed Resident #4 was seated in the Unit 1 Dining/Activity Room across from the nurses' station with a long white mustache and beard. The resident…

  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 before2025-01-31 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  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 observations, interviews, facility policy review and record review the facility failed to provide a safe, functional, sanitary environment for three (3) of four (4) days of survey that affected Residents #2, #4, #7 and #8. Finding included: Record review of the facility policy titled HOUSEKEEPING CLEANING PROCEDURES dated 6/18 revealed RESPONSIBILITY: Housekeeping Staff. PROCEDURE: .4. Survey room/remove used items/trash .11. Spot clean walls/damp wipe vertical surfaces .Dust mop and damp mop floor .Weekly Procedure .4. Wipe walls . Record review of a typed statement on facility letterhead and signed by the Administrator, undated, revealed (Proper name of facility) does not have a pest control policy. We have a [NAME] of Rights for a clean environment. Record review of the RESIDENT BILL OF RIGHTS with a history of 1/23 revealed Facility residents shall have the right to .32. A safe clean, comfortable home like environment . Resident #7 On 1/28/25 at 3:10 PM, observation revealed Resident #7 was resting quietly in her bed in her room with enteral feeding solution suspended…

  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

“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

$97,553 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $4,147 — penalty dated 2025-01-31
• $93,406 — penalty dated 2025-01-31
• Medicare payment denial — starting 2025-05-01 for 37 days

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.

Who owns this facility

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

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 73% 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 $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 13% 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.

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

Cost & finances

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

What families pay in MS