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Willow Creek Retirement Center

49 Willow Creek Lane, Byram, MS 39272 · For profit - Limited Liability company · 88 certified beds · (601) 863-4201 Medicare & Medicaid certified

Call the home — (601) 863-4201 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Jun 2026Resident-funds citation (F0565)Behavioral-health or dementia-care citations — no harm found (F0740, F0758)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$8,018 in federal fines
Insights

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

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jun 2026
  • it has a citation for mishandling residents’ money or property (F0565)
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,018 in federal fines (most recent 2024-09-12)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • about 25% of its spending goes to commonly-owned related companies

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

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
7215 S Siwell Rd · (601) 373-2204 · Call to confirm hours
Pharmacy
7264 Siwell Rd · (601) 371-8662 · Call to confirm hours
Grocery
Kroger1.9 mi
6745 S Siwell Rd · (601) 863-2001 · Call to confirm hours
Park
118 Elton Rd · (601) 892-8806 · Typically dawn to dusk
Place of worship
4207 Rainey Rd · (601) 487-2330

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 3 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 improved from 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased32.7%20.5%15.4%worse
Long-stay residents who lose too much weight5.4%6.2%5.4%typical
Long-stay residents with a catheter left in their bladder2.2%1.4%0.9%worse
Long-stay residents with a urinary tract infection0.4%2.5%2.0%better
Long-stay residents with depressive symptoms1.9%1.6%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury2.4%3.1%3.3%better
Long-stay residents whose ability to walk worsened30.7%19.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication22.3%23.8%18.9%worse
Long-stay residents given the seasonal flu vaccine90.9%97.0%95.3%typical
Long-stay residents with pressure ulcers11.7%6.3%4.7%worse
Long-stay residents with worsening bladder/bowel control29.8%20.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table31.7%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.7%2.5%1.4%worse
Short-stay residents given the seasonal flu vaccine96.7%84.6%79.4%better
Short-stay residents rehospitalized after admission26.7%27.7%22.6%worse
Short-stay residents with an outpatient ER visit16.3%15.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.002.431.67worse
Long-stay outpatient ER visits per 1,000 resident days2.582.861.80worse

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.

57.1% 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 120 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.1%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
77.2%U.S. median 56.6%
Met the expected recovery
0.46U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 77.2% 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 57 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 21% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF57.1%CMS range 46.7–64.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 6.5–13.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge77.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge79.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge63.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay1.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.5%CMS range 4.5–11.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.101.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.55
RN hours/ resident / day
1.09
LPN hours/ resident / day
2.41
Aide hours/ resident / day
4.05
Total nurse hours/ resident / day
0.33
RN hoursweekends
52.9%
Total nursing turnover
57.1%
RN turnover

How full it usually is: this home is certified for 88 beds and averages 79.3 residents a day — about 90% occupied, or roughly 9 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.550 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.41 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 3.64 hrs/resident/day on weekends vs 4.22 on weekdays — 14% thinner on weekends. RN hours go from 0.64 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%.

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

Inspection trend

7
deficiencies at the latest standard inspection (2026-03-05)
4
at the previous standard inspection (2024-11-07)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · G2024-09-12 · 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

    Based on interviews, record review, and facility investigation review, the facility failed to provide adequate supervision to prevent an accidental coffee burn for one (1) of the four (4) sampled residents. Resident #1 Findings included: Record review of the Facility Investigation with completion date 9/06/24 revealed the facility reported the incident of coffee spill with burn injury of Resident #1 to the State Agency (SA) and appropriate agencies in accordance with state and federal guidelines initially on 9/03/24 with final report submitted on 9/06/24. According to the Facility Investigation, the resident was served coffee on the morning of 9/03/24 at approximately 7:00 AM, observed capably drinking the coffee without assistance, then at 7:08 AM the resident rested the covered coffee cup on his stomach and it fell and tumbled toward the resident's left thigh, spilling and causing a burn injury to the resident, unobserved by facility staff. Further record review of the Facility Investigation included hospital progress notes and discharge instructions which revealed that 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 · Past Non-Compliance
  • Potential for harm · Dcited before2026-06-04 · 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 record review, facility policy review and interviews, the facility failed to ensure that a resident was protected from physical abuse when the Resident Representative (RR) struck the resident in the face. for one (1) of seven (7) sampled residents. (Resident #2).Findings Included:Record review of the facility policy Abuse, Neglect and Exploitation with a revision date 5/25/24, revealed .Mistreatment means inappropriate treatment or exploitation of a resident.Physical Abuse includes, but is not limited to hitting, slapping.It also includes controlling behavior through corporal punishment.The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves.III. Prevention of Abuse. E. Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives.Record review of the Facility Investigation dated 6/02/26 revealed that on 6/2/26 at…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-04 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect 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 observation, record review, facility policy review and interviews, the facility failed to ensure that residents were free from the misappropriation of resident property and exploitation when a licensed nurse signed for and took scheduled medication delivered by the pharmacy for one (1) of four (4) residents reviewed for medication administration. (Resident #1). Findings Included:Record review of the facility policy, Abuse, Neglect and Exploitation with a revised date of 05/25/24 revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Record review of the Facility Investigation dated 4/20/26 revealed that on 4/17/26, Registered Nurse (RN) #1 received for two (2)…

    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 · Fcited before2026-03-05 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, the facility failed to follow infection prevention and control practices during resident care by failing to perform hand hygiene during incontinent care (Resident #66), failing to implement Enhanced Barrier Precautions during catheter care (Resident #13), and contaminating environmental surfaces with soiled gloves during wound care (Resident #36) for three (3) of four (4) care observations.Findings include: A review of the facility's policy, Infection Prevention and Control Program, revised 3/23/23, revealed, .It is the policy of this facility to.maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A review of the facility's policy, Hand Hygiene, revised 6/12/22, revealed, .Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection.Policy Explanation and Compliance Guidelines.1. Staff will perform hand hygiene…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably 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, interview, record review, and facility policy review, the facility failed to ensure a resident's right to reasonable accommodation of communication needs when a functioning bedside telephone was not provided for one (1) of (18) sampled residents. Resident #9.Findings include:A review of the facility's policy, Resident Rights, revised 10/24/22, revealed, .Resident rights.The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.A record review of the Face Sheet revealed the facility admitted Resident #9 on 6/3/25 with diagnoses including Alzheimer's Disease.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/25, revealed Resident # 9 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated his cognition was severely impaired.On 3/2/26 at 12:37 PM, during an observation and interview, Resident #9 had a telephone sitting at the bedside which was not functioning. Resident #9's wife stated…

    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 · D2026-03-05 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to a clean, comfortable, and homelike environment when the air conditioning vent in the resident's room contained excessive dust and debris for one (1) of (18) sampled residents. Resident #9.Findings include:A review of the facility's policy, Resident Rights, revised 10/24/22, revealed, .Resident rights.8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment.A record review of the Face Sheet revealed the facility admitted Resident #9 on 6/3/25 with diagnoses including Alzheimer's Disease.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/25, revealed Resident # 9 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated his cognition was severely impaired.On 3/2/26 at 12:37 PM, during an observation, the air conditioning vent in Resident #9's room contained visible dust and debris.On 3/3/26 at 1:58 PM, during an observation and interview, the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-05 · 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 resident's comprehensive care plan intervention related to Enhanced Barrier Precautions for one (1) of (18) care plans reviewed. Resident #13.Findings include:A review of the facility's policy, Care Plans, updated 2/20/20, revealed, Each resident will have a person-centered plan of care to identify problems, needs, and strengths that will identify how the interdisciplinary team will provide care.Procedure.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 revealed Resident #13 had a Focus of The resident has indwelling foley catheter. with Interventions that included Enhanced Barrier Precautions.On 3/3/26 at 2:14 PM, during an observation, Certified Nursing Aide (CNA) #1 assisted by CNA #2 provided Foley catheter care to Resident #13. Staff did not wear a gown while providing catheter care despite the care plan intervention requiring Enhanced…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, the facility failed to ensure a Foley (indwelling catheter) was properly secured with a leg strap to prevent catheter movement and trauma for one (1) of two (2) residents reviewed for urinary catheters. Resident #13.Findings include:A review of the facility's policy, UTI (Urinary Tract Infection) Prevention with Indwelling Catheter Use, undated, revealed, .A resident with an indwelling catheter is susceptible to urinary tract infections.Policy Explanation.7. Catheter tubing should be secured to the resident's leg or bed clothing to prevent pulling and irritation of the urinary meatus.On 3/3/26 at 2:14 PM, during an observation, Certified Nursing Aide (CNA) #1 assisted by CNA #2 provided Foley catheter care to Resident #13 and the catheter tubing was not secured with a leg strap. On 3/4/26 at 2:34 PM, during an interview, CNA #2 confirmed Resident #13 did not have a leg strap in place and stated she forgot to obtain one. CNA #2 stated the purpose of the leg strap was to keep the Foley catheter from 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 · D2026-03-05 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were stored securely when medications were left unattended at a resident's bedside for one (1) of two (2) medication storage observations. Resident #33.Findings include:A review of the facility's policy, Medication Storage, undated, revealed, .Medication supply must be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. All drugs, treatments and biologicals must be stored securely.On 3/3/26 at 9:00 AM, during an observation and interview, Resident #33 pointed to a medication cup sitting on the bedside table. The medication cup contained six (6) pills described as three round pills, two pink pills, and one white oblong pill. Resident #33 stated she did not know why she had to take so many medications.On 3/3/26 at 9:10 AM, during an observation, Licensed Practical Nurse (LPN) #3 entered the room and spoke with Resident #33 regarding the medications. LPN #3 stated to the resident that when she previously left…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency, specifically, the facility was cited for failing to ensure proper infection control practices related to hand hygiene during Percutaneous Endoscopic Gastrostomy (PEG) tube site care during an annual recertification survey on 11/7/24 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of seven (7) deficiencies cited. F880Findings include:A review of the facility's policy, Quality Assurance Performance Improvement, revised 5/7/18, revealed .Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life.Record review of the Provider History Profile revealed the facility received a…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-06 · tag F0740 — failed to provide behavioral / mental-health care — pattern
    Ensure each resident must receive and the facility must provide necessary behavioral health care and 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 record review, interview and facility policy review the facility failed to provide necessary behavioral services by qualified staff to ensure residents' dignity, privacy, and safety and failed to promote mental and psychosocial well-being for five (5) of (5) residents. Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5. Findings include:Record review of the Facility Policy titled, Dementia Care with an implementation date of 1/04/26 revealed, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of or is diagnosed with dementia, to meet his or her highest practicable physical, mental and psychosocial well-being.4. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety. 5. Individualized, non-pharmacological approaches will be utilized, to include meaningful activities aimed at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · Ecited before2024-11-07 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure proper infection control practices were implemented during Percutaneous Endoscopic Gastrostomy (PEG) tube site care and wound care for two (2) of (19) sampled residents. Residents #14 and #30 Findings Include: A review of the facility's policy titled Hand Hygiene, dated 06/12/22 revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . If your task requires gloves, perform hand hygiene prior to donning gloves, and sanitize or wash hands after removing gloves . Resident #14 On 11/06/24 at 1:08 PM, during an observation of wound care, Licensed Practical Nurse (LPN) #1/Wound Care Nurse, performed a dressing change on Resident #14's right elbow. After removing the soiled dressing from the resident's arm, she placed it on the resident's bedside table without using a barrier and did not use a red biohazard bag for disposal. LPN #1 then proceeded to apply a new dressing without removing her soiled…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-07 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure the comprehensive care plan interventions were implemented during Percutaneous Endoscopic Gastrostomy (PEG) tube care for one (1) of 19 care plans reviewed. Resident #30 Findings Include: A review of the facility's policy titled Care Plans, dated 02/20/20 revealed, Each resident will have a person-centered plan of care to identify problems, needs, and strengths that will identify how the interdisciplinary team will provides care . PROCEDURE: . 6. Staff approaches are to developed for each problem/strength/need. Assigned disciplines will be identified to carry out the intervention . A record review of Resident #30's Comprehensive Care Plan with a start date of 4/4/2019 revealed Adequate fluid/nutritional intake .Intervention .Keep head of bed elevated at all times .Cleaning peg site with normal saline. Pat the site dry with gauze .for skin protection. On 11/06/24 at 1:25 PM, during an observation of PEG site care, Licensed Practical Nurse (LPN) #1 lowered the head of the bed 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-07 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure the physician orders were followed related to the care of a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube for one (1) of (19) sampled residents. Resident #30. Findings Include: A review of the facility's policy titled, Dressing Change, policy (undated) revealed, A dressing change will be done to promote wound healing, prevent infection and to provide an opportunity for wound assessment. On 11/06/24 at 1:25 PM, during an observation of PEG tube site care, Licensed Practical Nurse (LPN) #1 lowered the head of the bed to a flat position while Resident #30's feeding pump was infusing Glucerna 1.2 at 50 cubic centimeters (cc) per hour. LPN #1 then proceeded to clean the PEG site with gauze in a circular motion without drying the site afterward. On 11/06/24 at 1:35 PM, during an interview with LPN #1 , she admitted she forgot to place the feeding pump on hold before positioning the bed flat to conduct care. She acknowledged that she should have dried the site…

    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 · D2024-11-07 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review, and facility policy review, the facility failed to prevent significant medication errors for one (1) of six (6) residents observed for medication administration. Resident #9 Findings Include: A review of the facility's policy titled Medication Administration Guidelines, (undated), revealed, Medications are administered as prescribed .18. Prior to administration, the medication and dosage schedule on the resident's MAR/TAR or EMAR/ETAR is compared with the medication label. Information on the medication should be checked against the MAR/ETAR at least three times during the med preparation and administration process . During an observation on 11/04/24 at 8:35 AM, Licensed Practical Nurse (LPN) #3 pulled medications for Resident #9. While pulling medications for an order of Lorazepam Oral Tablet 0.5 mg (milligram) that was to be given once daily for Anxiety Disorder, LPN #3 instead pulled a tablet for Alprazolam 1 mg, 1.5 tablets (to equal 1.5 mg) to be given at bedtime. This medication was placed into the medication cup with 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, interviews, and facility policy review, the facility failed to provide care and services to promote healing and prevent infection for one (1) of four (4) residents that required wound care. Resident #2 Findings Include: Record review of the facility policy titled DRESSING CHANGE, (undated), revealed, A dressing change will be done to promote wound healing, prevent infection and to provide an opportunity for wound assessment. On 5/23/24 at 3:50 PM, an observation of Resident #2 revealed she was lying on her back in bed. The resident's incontinence brief was wet and had fecal matter present. There were two small open areas on her sacral area, with no bandage present. On 5/23/24 at 4:55 PM, an interview with the Assistant Director of Nurses (ADON) revealed she was assigned to the care of Resident #2 on 5/23/24. She stated she had not provided wound care to Resident #2. She explained that she intended to wait because evening meal trays had just been delivered to the hall and she had to assist with meal deliveries. She stated, when trays come out,…

    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 before2024-03-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review, and facility policy review, the facility staff failed to provide treatment and services in a manner to promote the healing and prevent complications of a pressure ulcer for one (1) of three (3) sampled residents with pressure ulcers. (Resident #2) Findings include: Review of the facility's policy, titled Dressing Change undated, revealed, Policy: A dressing change will be done to promote wound healing, prevent infection and to provide an opportunity for wound assessment . Review of the facility's policy, titled Hand Hygiene, reviewed 6/12/22, revealed Policy: All staff will perform hand hygiene procedures to prevent the spread of infection .Policy Explanation and Compliance Guidelines: 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. On 3/13/24 at 11:55 AM, an observation revealed the facility Treatment Nurse provided wound treatment for a Stage 2 pressure ulcer, with non-intact skin on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and facility policy review, the facility failed to provide care and services for a resident with an indwelling urinary catheter in a manner to prevent the potential for a urinary tract infection (UTI) for one (1) of two (2) sampled residents with indwelling urinary catheters. (Resident #6) Finding include: Record review of the facility policy titled, UTI Prevention with Indwelling Catheter Use, dated 1/27/2015, revealed, Policy: A resident with an indwelling catheter is susceptible to urinary tract infections . Policy Explanation . 3. Urinary drainage tubing should be positioned so as not to touch the floor . On 3/12/24 at 12:40 PM, an observation revealed Certified Nursing Assistant (CNA) #1 answered the call light for Resident #6, who was seated on the toilet in her room. The resident's catheter drainage bag and approximately three (3) inches of drainage tubing were lying on the floor next to the toilet. On 3/12/24 at 12:45 PM, in an interview with CNA #1, she…

    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 before2023-08-11 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    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

    Based on interview, record review, policy review, and review of the facility reported incident investigation, the facility failed to ensure residents were free from abuse and neglect for two (2) of four (4) residents reviewed for abuse and neglect. Residents #1 and #2. Findings include: Review of the facility's policy, Abuse Program, revised May 23, 2017, revealed, It is the policy of this facility to take all steps necessary to maintain an environment free of abuse and neglect. Each resident has the right to be free from verbal, sexual, physical and mental abuse, .Abuse means the will infliction of injury .intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse of all residents, irrespective of any mental or physical condition .cause physical harm, pain or mental anguish. It includes verbal abuse .and mental abuse .Willful, as used 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-11 · tag F0656 — failed to write and follow a full care plan — pattern
    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 interview, record review, policy review and facility investigation review, the facility failed to ensure that the comprehensive person-centered care plan was implemented for two (2) of four (4) residents reviewed for abuse and neglect. Residents #1 and #2 Findings include: Record review of the facility policy Care Plans updated 2/20/2020 revealed, Policy: Each resident will have a person-centered plan of care to identify problems, needs and strengths 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. Resident #1 Record review of the Facility Investigation dated 6/19/23, revealed that on 6/16/23, Certified Nurse Aide (CNA) #1 was determined to have yelled and used derogatory language toward Resident #1 during routine care. Record review of the Care Plan for Resident #1 revealed the resident had a Care Plan with a start date of 5/15/23 'Description .Decision making: Impaired Cognitive skills for daily…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-02-23 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, and facility policy review, the facility failed to maintain a clean ice machine for the residents as evidenced by white, red, and black residue build up on the inside and outside of the ice machine, observed on one (1) of five (5) kitchen tours. Findings include: Review of the facility policy titled, Cleaning Instructions Ice Maker and Dispenser, dated 9/04, revealed, Policy: Equipment shall be maintained in a clean and sanitary condition . Procedure: . The ice making system can be cleaned in place without disassembling the water system. The cleaning process should be performed at least every 6 months or more often if local water conditions dictate . An observation and interview on 2/21/23, at 8:08 AM with the Dietary Cook, revealed the ice machine to have streaks of white residue running down from the door covering the ice machine and down the left outer side of the ice machine. There were also observations of the following: 1. Streaks of faded white residue on the inside of the door covering the ice machine. 2. Red residue on the inside…

    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 · E2023-02-23 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident and staff interviews, record reviews, and facility policy review, the facility failed to document and act promptly to resolve grievances and recommendations from Resident Council Meetings for six (6) of 6 months of resident council meeting minutes reviewed. Findings include: A review of the facility policy titled, Resident and Family Grievances, with a date reviewed of 2/3/23, revealed, Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. 2. The Grievance Official, Administrator or Director of Nursing is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility . Policy Explanation and Compliance Guidelines: .8. Grievances may be voiced in the following forums . d. Verbal complaint during resident or family council meetings 10. Procedure: . b. The staff member receiving the grievance will record the nature and specifics of the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-23 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy review, the facility failed to honor the resident's right to make choices, as evidenced by residents having to remain out of bed during mealtimes for two (2) of four (4) residents reviewed for choices. Resident #15 and #24 Findings include: Review of the facility policy titled, Residents Rights, with the date reviewed/revised of 4/18/18, revealed . 6. Self-determination. The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: . b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. A record review of a signed letter provided by the Administrator, on the facility's letterhead, dated 2/23/23, revealed There is no written policy that care is not to be given during mealtimes. During an interview on 2/21/23 at 11:03 AM, Resident #24, revealed she preferred to lay down at…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-23 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record reviews, and facility policy review, the facility failed to shave a resident that required assistance with shaving for one (1) of 18 residents reviewed for Activities of Daily Living. Resident #48 Findings include: Review of the facility policy titled, A.M. Care revealed, A.M. care will be given to residents daily . Responsibility: All Nursing Assistants. Equipment: . 7. Razor, shaving cream . An observation on 2/21/23 at 9:01 AM, revealed Resident #48 unshaven with facial hair about ½ inch long. He stated he hasn't been shaved in a month, but when he was able to do it for himself, he shaved daily. An observation on 2/21/23 at 10:00 AM, revealed Resident #48 receiving a bed bath. In an interview on 2/21/23 at 3:15 PM, Certified Nursing Assistant (CNA) #1 confirmed she had given Resident #48 a bath this morning. She confirmed that she had washed his face but didn't offer him a shave, because she didn't think he needed it. However, after looking at the resident again, she stated he had needed to be shaved. During an interview on 2/22/23 at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review, and facility policy review, the facility failed to provide appropriate catheter care of for one (1) of three (3) residents reviewed for a catheter care. Resident #29 Finding's include: Review of the facility policy titled, Catheterization Policy, with no revision date, revealed, . Reminders -Tubing and bag should be properly positioned below hip level . An observation on 2/21/23 at 8:45 AM, revealed Resident #29 lying in bed with a nephrostomy bag attached to the head of the bed on her right side. The head of the bed that was elevated to approximately 30 degrees. An interview on 2/22/23 at 8:40 AM, with Certified Nurse Assistant (CNA) #2, revealed that Resident #29 gets turned every two hours. The CNA stated the urine catheter bag does not affect her turning, because it always stays at the head of the bed. An observation on 2/22/23 at 9:22 AM, revealed, Resident #29 was lying in bed with her nephrostomy bag at the head of the bed, that was elevated approximately 30 degrees. An observation and interview on 2/22/23 at 1:41 PM, with the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record reviews and facility policy review, the facility failed to ensure as-needed (PRN) psychotropic medications were discontinued after 14 days, for one (1) of six (6) residents reviewed for unnecessary medications. Resident # 9 Findings include: Review of the facility policy titled, Psychotropic Medication Policy and Procedure with a revision date of 3/21/17, revealed Policy: Physicians//providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. Standards: 1. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the facility to include regular review for continued need, appropriate dosage, side effects, risks and or benefits . 9. Orders for PRN psychotropic medications will be time limited (i.e., times 2 weeks) and only for specific clearly documented circumstances. PRN orders for anti-psychotic drugs are limited to 14 days unless the prescriber evaluates the resident for the…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$8,018 in federal fines across 1 penalty.

  • $8,018 — penalty dated 2024-09-12

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 BRIAR HILL MANAGEMENT — 6 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 →

RatingThis homeChain avg
Overall 2 of 53.2-1.2 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 4 of 54.5-0.5 vs chain
Quality measures 2 of 51.8+0.2 vs chain
The other 5 homes this chain runs (chain average 3.2★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
PHILIPPE, LYNNIndividualDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/28/2008
ROTOLO, DAVIDIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/28/2008
ROTOLO, ROBERTIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/28/2008
BRIAR HILL MANAGEMENT, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
BURLISON, SANDYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/25/2019
BURNS, SHARONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/28/2008
GREEN, DONNAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/04/2010
KING, CURTISIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2016
MUHA, ASHLEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/04/2010
WALTERS, JOHNNIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/12/2026
WHITE, DEBORAHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/12/2014
WHITLOW, CARRIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/05/2022
OMNICARE LLCOrganizationADP OF THE SNFsince 05/01/2017
WCR LLCOrganizationADP OF THE SNFsince 01/28/2008
ESTES, TIMOTHYIndividualADP OF THE SNFsince 11/11/2008
RUBERTINO, FROSINIIndividualADP OF THE SNFsince 09/18/2017

CMS files one row per role, so the 30 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$9.4M
Net patient revenuemost recent cost report
+2.7%
Operating marginrevenue minus expenses
$2.3M
Related-party expense25% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 13%Other / private 13%

About 74% 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 $2.3M paid to related parties — landlords or management companies under common ownership — equal to about 25% 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

$302per resident / day
operating cost
$9,172per month
≈ monthly operating cost
$310per day
avg. revenue, all payers

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

What families pay in MS

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 255300. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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