Great Oaks Rehabilitation And Healthcare Center
111 Chase Street, Byhalia, MS 38611 · For profit - Corporation · 60 certified beds · (662) 838-3670 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0602), cited Oct 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,788 in federal fines (most recent 2025-05-22)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (64%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 25.2% | 20.5% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.7% | 6.2% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.7% | 1.4% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.7% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.9% | 1.6% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 3.1% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 38.8% | 19.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 43.1% | 23.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.1% | 97.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.1% | 6.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.9% | 20.7% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.2% | 21.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 3.3% | 2.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 98.7% | 84.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 33.9% | 27.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.2% | 15.5% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
51.5% 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 175 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 52.2% 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 46 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 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 41% 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.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 51.5%CMS range 44.7–58.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 8.2–14.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 52.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 56.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 37.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 58.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 23.9% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.8%CMS range 5.3–11.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.32 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 60 beds and averages 47.0 residents a day — about 78% occupied, or roughly 13 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 4.32 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.31 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 3.78 hrs/resident/day on weekends vs 4.53 on weekdays — 17% thinner on weekends. RN hours go from 0.41 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 64% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · Gcited before2025-05-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observations, resident, staff, and family interviews, record review, and facility policy review, the facility failed to maintain a safe environment and provide adequate supervision and equipment to prevent accidents for one (1) of four (4) sampled residents. Resident #1. Specifically, staff removed the resident's bed rails without a safety assessment and as a result, the resident rolled out of bed, during care and sustained a head laceration, suffered pain and required emergency room treatment, including x-rays and stitches. Findings Include: Review of the facility policy titled Fall Prevention Program with a review date of 6/10/24 revealed under, Policy: All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change thereafter. Based on the results of this assessment, specific interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. Record review of the NSG (Nursing): Device Evaluation dated 11/26/24 revealed under, Fall History . Fell…
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.
- Potential for harm · Dcited before2026-05-20 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed and transmitted within CMS (Centers for Medicare and Medicaid Services) required time frames for one (1) of 14 MDS assessments reviewed. Resident #30.Findings Include:Record review of CMS Version 3.0 Manual revealed under Chapter 5, Submission and Correction of the MDS Assessments.5.2 Timeliness Criteria. For all non-admission OBRA (Omnibus Budget Reconciliation Act) and PPS (Prospective Payment System) assessments, the MDS Completion Date must be no later than 14 days after the Assessment Reference Date (ARD).For Entry and Death in Facility tracking records, the MDS Completion Date must be no later than 7 days from the Event Date.An interview with the Administrator on 5/19/26 at 10:21 AM revealed the facility did not have a policy regarding the timely encoding and transmission of Minimum Data Set (MDS) assessments and stated staff followed the Resident Assessment Instrument (RAI) Manual for guidance.Record review of Resident #30's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-06 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to notify the provider to clarify missing orders for previously established interventions following a resident's return from the hospital. This resulted in a lapse in continuity of care for one (1) of three (3) residents reviewed for hospital readmission. Resident # 1.Findings Include: Record review of July 2025 Order Summary Report for Resident #1 revealed an abduction pillow, and nutritional supplement was ordered prior to hospital transfer on 8/15/25. Review of the After Visit Summary dated 8/18/2025 showed no mention of these interventions. Upon readmission, the facility did not contact the provider to clarify whether the interventions should be resumed, and the interventions were not reinstated. During an interview on11/6/25 at 8:15 AM, with the Assistant Director of Nursing (ADON) she stated the facility only re-enters what the hospital sends back after clarification with the provider. She verified they did not seek clarification about pre-hospital interventions of the abduction pillow or nutritional supplement.In…
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.
- Potential for harm · D2025-11-06 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 staff interview, record review and facility policy review the facility failed to report an injury of unknown origin to the State Agency (SA) as required for one (1) of three (3) residents reviewed for injuries. Resident #1.Findings Include:Record review of the facility's policy titled Abuse Prohibition Policy revealed: The Abuse Coordinator will report such allegations to the state agency in accordance with the state law .The Abuse Coordinator will report .injuries of unknown source with serious bodily injury within two (2) hours of the allegation. Review of the facility's investigation, provided by the Administrator (ADM), revealed that on 5/28/25, Resident #1 experienced a syncopal episode and was transferred to the emergency room (ER). The Responsible Party (RP) later informed the facility that when Emergency Medical Services (EMS) transferred the resident from bed to stretcher on 5/28/25, the resident yelled out in pain and that EMS was not gentle. The investigation file included no documentation of staff witness statements, no record of conversation with the RP prior…
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.
- Potential for harm · D2025-11-06 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 conduct a prompt and thorough investigation of an injury of unknown origin to determine whether abuse, neglect, or a clinical cause contributed to the injury for one (1) of three (3) residents reviewed for injuries. Resident #1.Findings Included: Record review of the facility's policy titled Abuse Prohibition Policy revealed: Investigation: 1. The facility will thoroughly investigate all alleged violations and take appropriate actions. 5. Investigations will be prompt, comprehensive, and responsive to the situation and contain founded conclusions.Review of the facility's investigation, provided by the Administrator (ADM), revealed that on 5/28/25, Resident #1 experienced a syncopal episode and was transferred to the emergency room (ER). The Responsible Party (RP) later informed the facility that when Emergency Medical Services (EMS) transferred the resident from bed to stretcher on 5/28/25, the resident yelled out in pain and that EMS was not gentle. The investigation file included no…
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.
- Potential for harm · D2025-11-06 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to ensure a complete and accurate medical record was maintained when a verified exercise order was not entered into the electronic medical record, resulting in an incomplete clinical record for one (1) of three (3) sampled residents reviewed for medical record accuracy .Resident #1.Findings Included: Record review of a Return to Work/School form provided by the Orthopedic Physician's office for Resident #1 revealed and order, dated 7/18/25, for work on passive exercises for lower extremity due to patient non weight bearing status for 1-2 times a week. Work on active range of motion for upper extremity to ensure tone and minimalize stiffness for 1-2 times a week. The form was initialized and dated 7/22/25. Review of Resident #1's physician orders for July 2025 revealed no documentation that the new exercises were ordered. As a result, the services were not initiated as ordered. During an interview on 11/5/25 at 12:00 PM, the Director of Nursing (DON) stated that the nurse practitioner (NP) verified the order for therapy…
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.
- Potential for harm · D2025-06-25 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and facility policy review, the facility failed to notify a resident and/or a legal representative of the risks and benefits of using a psychotropic medication for four (4) of 42 residents reviewed for psychotropic drug use. Resident #8, #13, #21, and #23 Findings Include: Review of the facility policy titled Psychotropic/Psychoactive Medication Policy with a revision date of 6/24/25 revealed under, Policy Implementation: . 5. All residents have full rights to participate or refuse treatment. Before initiating or increasing psychotropic medication the resident and or responsible party must be notified of and have the right to participate in their treatment, including the right to accept or decline the medication. The risk and benefits should be clearly explained . Resident #8 Record review of Resident #8's Order Summary Listing revealed the following orders: - Dated 3/06/25: Buspirone HCL (hydrochloride) oral tablet 5 MG (milligrams) give 1 (one) tablet by mouth three…
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.
- Potential for harm · D2025-06-25 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident and staff interview, record review and facility policy review, the facility failed to ensure a residents call light was accessible for one (1) of 50 residents in the facility. Resident #155 Findings Include: Review of the facility policy titled Resident Call System with a revision date of 3/28/23 revealed under, Policy Interpretation and Implementation: 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor . An observation of Resident #155 on 6/23/25 at 9:26 AM revealed she was lying in bed with the call light on the floor under the bed. During an interview, Resident #155 voiced this happens often. She stated, The staff walk out and don't give me my call light, and I don't have any way to call them. She explained she prefers her room door left open so she can call out to staff if needed. An observation and interview with Certified Nurse Aide (CNA) #1 on 6/23/25 at 9:36 AM confirmed Resident #155's call light was on the floor. CNA #1 stated the call light…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-25 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and record review the facility failed to provide a resident with a wheelchair in good repair for one (1) of 50 residents requiring a wheelchair in the facility. Resident #49 Findings Include: The facility provided a statement on letterhead that read, (Proper name of facility) does not have a policy specifically regarding wheelchair good repair/condition. During an observation of Resident #49 on 6/23/25 at 10:38 AM, he was propelling himself in his wheelchair down the hallway and into his room. Both arm rest were in disrepair, torn and tattered with the white foam visible and a silver screw head exposed on both sides. An observation and interview with Registered Nurse (RN) #1 on 6/24/25 at 7:55 AM confirmed Resident #49's wheelchair arm rest were in poor condition and stated he could get injured or scraped. An interview with the Director of Nursing (DON) on 6/24/25 at 9:10 AM revealed the wheelchair for Resident #49 was provided by the facility when he was admitted . She confirmed his chair should be in good repair and stated the resident could…
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.
- Potential for harm · D2025-06-25 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, record review, and facility policy review, the facility failed to accurately code a Minimum Data Set (MDS) for one (1) of 16 residents' MDS reviewed (Resident #52). Findings include: Review of the facility policy titled, MDS Coding Policy, last reviewed 6/02/2025, revealed, Proper Name affiliated facilities utilize the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely, and accurately. Review of the Interdisciplinary Discharge Summary revealed Resident #52 was discharged to Proper Name Health and Rehab on 3/26/25. Review of the Admission/Discharge MDS for Resident #52 revealed Section A2105 - Discharge Status was coded 04 - Short-Term General Hospital. During an interview with the MDS nurse on 6/24/25 at 12:00 PM, she confirmed after review of the Admission/Discharge MDS that it was not accurately coded because Resident #52 was discharged to another rehabilitation facility and not to the hospital. She stated the purpose of accuracy of the MDS is to ensure there is an…
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.
- Potential for harm · Dcited before2025-06-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, staff interviews, and record review, the facility failed to ensure a safe environment by not preventing hazardous substances from being stored in a resident's room, thereby creating the potential for accidental ingestion and harm. Specifically, the facility failed to prevent a resident's family from placing two homemade containers of ant bait (containing boric acid) in the resident ' s room, which remained accessible to Resident #15 and potentially to other cognitively impaired, wandering residents. This deficient practice affected one (1) of fifty (50) residents reviewed (Resident #15). Findings Include: Review of the typed statement on facility letterhead revealed the facility did not have a policy regarding storing hazardous materials in residents rooms and was signed by the Administrator. During an observation and interview in Resident #15's room on 6/23/25 at 12:00 PM with Licensed Practical Nurse (LPN) #1, she confirmed the presence of two (2) four-ounce, white, round, wide-mouth…
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.
Show the remaining 11 citations
- Potential for harm · D2025-06-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure that an indwelling urinary catheter was clinically indicated and ordered by the provider for one (1) of three (3) residents reviewed with catheters (Resident #105). Findings include: Review of the facility policy titled, Indwelling (Foley) Catheter Insertion, Male Resident, revised March 2024, revealed Preparation: 2.) Verify that there is a physician's order . An observation on 6/23/25 at 10:00 AM revealed Resident #105 had an indwelling urinary catheter. A continued interview with the resident revealed he stated that they put the catheter in him while in the hospital and never took it out, but confirmed he did not know why he had it. During an interview with Registered Nurse (RN) #1 on 6/24/25 at 9:00 AM, she revealed after review of the hospital After Visit Summary for Resident #105 that there was no mention of the resident having a catheter order. She stated that it is not uncommon for a resident to be admitted to the facility with a catheter and no…
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.
- Potential for harm · E2024-10-01 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident and staff interviews, record review, and facility policy review the facility failed to provide sufficient staffing to ensure residents needs were met in a timely manner for five (5) of seven (7) residents reviewed. Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7. Findings Include: Record review of the facility policy, Staffing, Sufficient and Competent Nursing with reviewed date of 03/2023 revealed, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: a. assuring resident safety, b. attaining or maintaining the highest practicable physical, mental, and psychosocial well being of each resident .d. responding to resident needs. On 09/30/24 at 9:50 AM, an interview with Director of Nursing (DON), 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.
- Potential for harm · D2024-10-01 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff and resident interview, record review and facility policy review the facility failed to protect a resident's right to be free from misappropriation of property for one (1) of five (5) sampled residents. Resident #1. Findings include: Record review of the facility's, Abuse Prohibition Policy with revision date of 11/07/23 revealed, The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. Record review of the facility policy, Resident Rights with a revision date of February 2021 revealed, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .c. be free from abuse, neglect, misappropriation of property, and exploitation Record review of the facility Investigation of the allegation reported to Administrator by Resident #1 revealed that she had previously allowed Certified Nursing Assistant (CNA) #1 to order her some food on her food application (app) on her phone because she did not have a way…
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.
- Potential for harm · Dcited before2024-05-15 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 staff and resident Resident Representative (RR) interview, record review and facility policy review the facility failed to notify the RR of a change in a medication for one (1) of three (3) residents reviewed. Resident #1. Findings Included: Review of the facility policy titled, Change of Condition and Physician/Family Notification with a review date of January 2023 revealed Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories: .A need to significantly alter treatment Procedure . the licensed nurse will contact the resident's family and their physician. On 05/15/24 at 9:20 AM, an interview with Resident #1's RR revealed that Resident #1 was admitted to the facility on [DATE] for skilled therapy services. She revealed that he had Diabetes Insipidus and had been on Hydrocortisone and Desmopressin medications since 1980. The RR revealed the Family Nurse Practitioner (FNP) at the facility discontinued…
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.
- Potential for harm · E2024-01-04 · tag F0880 — failed to prevent and control infections — patternProvide 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 potential spread of infection when staff failed to sanitize hands between a respiratory treatment and peg (percutaneous endoscopic gastrostomy) tube medication administration and failed to clean and properly store a respiratory mask and peg tube syringe for (1) one of (8) resident care observations. Resident #15 Findings include: Review of the facility policy titled, Administering Medication, revised April 2019, revealed Policy heading: Medications are administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation: 25.) Staff follows established facility infection control procedures (e.g. (for example) handwashing, antiseptic technique, and gloves) for the administration of medications, as applicable . Review of the facility policy titled, Infection Prevention and Control Program, reviewed January 2023, revealed Policy Statement: An infection prevention and…
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.
- Potential for harm · D2024-01-04 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 staff interview, record review and facility policy review, the facility failed to ensure the resident's right to formulate an Advance Directive (Resident #15 & 50) or identify if a resident had an Advance Directive (Resident #34) for three (3) of 18 residents reviewed for Advance Directives. Findings Include: Review of the facility policy titled, Advance Directives with a revision date of 8/2023 revealed, Policy Interpretation and Implementation .1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical treatment and to formulate an advance directive if he or she chooses to do so . Record review of Resident #34's Advance Directive Policy that was electronically signed by the resident's representative revealed there was no indication if the resident had an Advance Directive. Record review of Resident's #15 and #50's Advance Directive Policy that was electronically signed by the resident for Resident #15 and Resident Representative for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-04 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review and Resident Assessment Instrument (RAI) Manual review, the facility failed to submit Minimum Data Set (MDS) assessments within 14 days of the MDS Completion Date for three (3) of 18 MDS resident assessments reviewed, Resident #12, Resident #14, and Resident #32. Findings Include: An interview on 1/4/24 at 11:00 AM, with the Director of Nurses (DON) revealed the facility uses the RAI Manual as the MDS Policy for the facility. Review of the RAI Manual dated October 2023 revealed under 5.2 Timeliness Criteria .facilities participating in the Medicare and Medicaid programs must meet the following conditions: .Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument .Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (VO200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14…
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.
- Potential for harm · D2024-01-04 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 observations, staff interview, record review and facility policy review the facility failed to implement a care plan for Activities of Daily Living (ADL) for one (1) of 18 residents care plans reviewed. Resident #6. Findings include: Review of the facility policy titled, Care Plan, Comprehensive Person-Centered with a reviewed date of 01/2023 revealed under Policy Interpretation and Implementation .1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. Record review of Resident #6's care plans revealed the resident had an ADL care plan had a deficit in self-performance related to her diagnosis of Metabolic Encephalopathy and required extensive assistance by 1 staff for toileting that was initiated on 11/22/23. On 01/02/24 at 1:59 PM, an interview and observation of Resident #6 revealed the resident was lying in bed with her eyes closed and a foul odor. An…
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.
- Potential for harm · D2024-01-04 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and facility policy review the facility failed to administer a medication as the physician ordered for (1) one of 28 medication administration opportunities. Findings include: Review of the facility policy titled, Administering Medication, revised April 2019, revealed Policy heading: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4.) Medications are administered in accordance with prescriber's orders . 10.) The individual administering the medication checks the label three times to verify the right resident, right medication, right dose, right time, and right method (route)of administration before giving the medication . An observation of Licensed Practical Nurse (LPN) #1 on 1/03/24 at 8:35 AM, revealed she prepared medication for Resident #15, locked her cart and entered room to administer the medications. All liquid and crushed medications were administered via percutaneous endoscopic…
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.
- Potential for harm · D2024-01-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and family interview and facility policy review the facility failed to provide timely incontinent care for a resident who had a bowel movement as evidenced by the resident waiting an hour and a half for incontinent care for one (1) of 18 Residents sampled. Resident #6 Findings include: Review of the facility policy titled, Activities of Daily Living (ADL), Supporting with a revision date of March 2018 revealed Policy Statement .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene . Review of the facility policy titled Perineal Care with a revision date of 7/21/18 revealed Purpose .The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. An interview and observation of Resident #6 on 1/02/24 at 1:59 PM, revealed Resident #6 was lying in bed…
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.
- Potential for harm · D2024-01-04 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and policy review the facility failed to ensure medications were secured when a medication cart was left unlocked and unattended with medications left on top of the cart for (1) one of (5) five medication administration observations. Findings include: Review of the facility policy titled, Storage of Medications, revised April 2019, revealed, Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 9.) Unlocked carts are not left unattended . An observation of Registered Nurse (RN) #1 during medication administration on 1/03/2024 at 8:00 AM, revealed RN #1 left the medication cart to go get supplies. She stated I will be right back and walked towards the nurse's station leaving the medication cart unlocked and a cup with an inhaler in it on the top of the cart. An interview with RN #1 on 1/03/24 at 8:04 AM she confirmed she left her medication cart unlocked and left 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.
“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.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,788 in federal fines across 1 penalty.
- $8,788 — penalty dated 2025-05-22
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 NEXION HEALTH — 51 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 2.3 | +0.7 vs chain |
| Staffing | 3 of 5 | 2.8 | +0.2 vs chain |
| Quality measures | 1 of 5 | 2.6 | -1.6 vs chain |
The other 50 homes this chain runs (chain average 2.2★, per CMS)
Showing 40 of 50; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NEXION HEALTH OF OHI INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/29/2018 |
| NEXION HEALTH LEASING, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/29/2018 |
| NEXION HEALTH, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/29/2018 |
| BOLT, BRETTON | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/29/2018 |
| KIRLEY, FRANCIS | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 03/29/2018 |
| LEE, BRIAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/29/2018 |
| OSWALD, JOHN | Individual | CORPORATE DIRECTOR | — | since 03/24/2022 |
| REID, JOHN | Individual | CORPORATE DIRECTOR | — | since 12/18/2018 |
| RINER, MEERA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/29/2018 |
| PIERCE, DANIEL | Individual | CORPORATE OFFICER | — | since 03/16/2021 |
CMS files one row per role, so the 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
3 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.
This home reported $488K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Mississippi Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 255311. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-20, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.