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Choctaw Residential Center

135 Residential Center Rd, Choctaw, MS 39350 · Non profit - Other · 120 certified beds · (601) 656-2582 Medicare & Medicaid certified

Call the home — (601) 656-2582 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Mar 2026Resident-funds citation (F0565)Behavioral-health or dementia-care citations — no harm found (F0740, F0758)$13,757 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 an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
  • it has a citation for mishandling residents’ money or property (F0565)
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $13,757 in federal fines (most recent 2025-03-06)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

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

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

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

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

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
517 Center Ave N · (601) 656-1440 · Call to confirm hours
Pharmacy
430 E Beacon St · (601) 656-2472 · Call to confirm hours
Grocery
716 Pecan Ave · (601) 656-2861 · Call to confirm hours
Park
240 W Beacon St · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 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.

Overall rating1★
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 increased19.8%20.5%15.4%worse
Long-stay residents who lose too much weight1.4%6.2%5.4%better
Long-stay residents with a catheter left in their bladder2.4%1.4%0.9%worse
Long-stay residents with a urinary tract infection3.2%2.5%2.0%worse
Long-stay residents with depressive symptoms0.0%1.6%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury4.5%3.1%3.3%worse
Long-stay residents whose ability to walk worsened19.2%19.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication18.7%23.8%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%97.0%95.3%typical
Long-stay residents with pressure ulcers4.8%6.3%4.7%typical
Long-stay residents with worsening bladder/bowel control14.5%20.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table14.8%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication2.4%2.5%1.4%worse
Short-stay residents given the seasonal flu vaccine97.6%84.6%79.4%better
Short-stay residents rehospitalized after admission31.5%27.7%22.6%worse
Short-stay residents with an outpatient ER visit16.0%15.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.942.431.67worse
Long-stay outpatient ER visits per 1,000 resident days2.952.861.80worse

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

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

47.9% 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 41 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.9%U.S. median 51.5%
Got home and stayed home
11.7%U.S. median 10.7%
Went back to hospital
65.7%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 65.7% 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 35 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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 SNF47.9%CMS range 31.4–63.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.7%CMS range 7.7–16.710.7%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 discharge65.7%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 discharge65.7%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 discharge60.0%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 identified60.0%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 discharge95.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened0.0%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 hospitalization7.6%CMS range 3.9–12.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.121.02Oct 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

0.44
RN hours/ resident / day
0.98
LPN hours/ resident / day
2.25
Aide hours/ resident / day
3.67
Total nurse hours/ resident / day
0.12
RN hoursweekends
41.4%
Total nursing turnover
0.0%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 112.2 residents a day — about 94% occupied, or roughly 8 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 3.67 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 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 3.11 hrs/resident/day on weekends vs 3.91 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.57 to 0.12 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% 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

10
deficiencies at the latest standard inspection (2025-03-06)
9
at the previous standard inspection (2023-08-24)

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.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · E2026-03-19 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to protect residents from abuse for two (2) of (2) residents reviewed for abuse (Resident # 1 and Resident # 3). Specifically, the facility failed to prevent resident-to-resident inappropriate sexual contact, when (2) incidents occurred when one resident touched another resident inappropriately.Findings include:Record review of the facility policy Resident Rights revised 3/24, revealed, .shall insure each resident of the following.J. THE RIGHT to be free from mental and physical abuses. Each resident has the right to a safe, secure, and homelike environment .The facility is responsible for implementing interventions to prevent resident-to-resident altercations and to ensure supervision sufficient to protect residents from harm. Resident #2 and Resident #3On 03/18/2026 at 10:15 AM, during an interview with Resident #3, the resident reported that she was involved in an incident with Resident #2 on 03/06/2026 in the front…

    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 · E2026-03-19 · 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 interview, record review, and facility policy review the facility failed to ensure residents received the necessary behavioral health care and services, specifically, the facility failed to proactively assess and implement effective behavioral interventions to address inappropriate sexual behaviors for two (2) of five (5) sampled residents reviewed for behavioral concerns. Resident #1 and Resident #3.Findings include:Record review of the facility policy Resident Rights revised 3/24, revealed, .shall insure each resident of the following.J. THE RIGHT to be free from mental and physical abuses. Each resident has the right to a safe, secure, and homelike environment .The facility is responsible for implementing interventions to prevent resident-to-resident altercations and to ensure supervision sufficient to protect residents from harm. Record review of the facility's Behavioral Health Services policy revealed, It is the policy of this facility to ensure all residents receive necessary behavioral health…

    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 · E2025-03-06 · 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 review, and facility policy review, the facility failed to resolve a resident grievance in a timely manner related to missing clothing, activities, and noisy environment for four (4) of seven (7) residents that attended resident council. Residents #27, #76, #100, and #309 Findings Include: Review of the facility policy titled Grievance/Complaint Policy unrevised, revealed, It is a policy of this facility that a resident/responsible party/legal representative has the right to voice grievances as follows: . All grievances should be directed/reported to the departmental supervisor and departmental director. Review of the facility policy titled Resident Personal Belongings unrevised, revealed under, Policy: It is the policy of this facility to protect the resident's right to possess personal belongings, such as clothing and furnishings, for their use while in the facility. Also revealed under, Policy Explanation and Compliance Guideline: . 7. The facility will exercise reasonable care for the protection of the resident's property from loss…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-03-06 · 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 observation, resident and staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for nail care, oral hygiene, and hand rolls for one (1) of 25 sampled residents. Resident #74 Findings Include: Review of the facility policy titled Comprehensive Care Plans unrevised, revealed under, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Review of Resident #74's Care Plan Report revealed under, Focus: I require total assistance with my ADL's (activities of daily living) r/t (related to) CVA (cerebrovascular accident) with left hemiplegia and bilateral hand contractures. Also revealed under, Interventions: Caregiver to don (apply) bilateral hand rolls to bilateral…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · 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, resident and staff interviews, record review and facility policy review, the facility failed to provide a safe, clean homelike environment for Residents #6, #11, and #60. This was for one (1) of four (4) hallways. Findings include: A record review of facility policy titled Safe and Homelike Environment, dated 2024, revealed, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . A record review of the facility policy titled, Deep Cleaning Rooms undated revealed, (6) Check all room curtains if it needs taking to laundry for washing. Resident #6 During an observation and interview on 03/03/25 at 3:10 PM, Resident #6's room was noted to have a large section of the wall (approximately 3 feet by 3 feet) with scratches and paint missing. Behind the resident's headboard of her bed, a piece of plywood measuring approximately 4 feet by 3 feet was noted to be attached to wall. The plywood had large chunks of wood missing which left uneven and splintered edges on the broken part as well as on the edges 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 · D2025-03-06 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure licensed nursing staff followed professional standards of practice for medication administration. This resulted in the administration of discontinued and incorrectly scheduled medications, and failure to administer prescribed medications. This deficient practice was identified for four (4) of 37 medication administration observation opportunities (Resident #39, Resident #90) CROSS REFERENCE F759 Findings include: A review of the policy titled Medication Administration revealed the following: Policy: Medications are administered by licensed nurses who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.Policy Explanation and Compliance Guidelines: Section 10 states that staff must ensure the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-06 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident dependent on staff for Activities of Daily Living (ADLs) received oral care and nail care for one (1) of 25 sampled residents. Resident #74 Findings Include: Review of the facility policy titled Activities of Daily Living Policy with a revision date of 7/2014, revealed under, Policy Statement: Based on previous evaluations and current date, the nursing staff, in conjunction with Attending Physician, Consultant Pharmacist, therapy staff, and others, will seek to identify the level of care a resident requires for ADLs. An observation of Resident #74, on 3/03/25 at 12:00 PM, revealed he was lying in bed with fingernails that were approximately 1 inch (in.) in length on the left hand with a brown substance on each nail and one nail that was broken off and hanging inside his palm. The residents' upper and lower teeth and lower gum line were covered in a thick white substance. An observation with interview on 3/05/25 at 7:50 AM with Resident #74 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 activities that met the interest of the residents for three (3) of 25 sampled residents. Resident #6, #9, and #41 Findings Include: Review of the facility policy titled Activities revealed under, Policy: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interest of each resident, as well as support their physical, mental, and psychosocial well-being. Resident #6 During an interview on 3/4/25 at 9:00 AM, Resident #6 stated the facility does not offer activities on the weekends and she would like to have activities on these days as well as during the week. She revealed she had been sick and had preferred to do activities in her room, but lately she felt better and wanted to participate in group activities. An interview with the Activity Director…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-06 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 hand rolls were applied for a resident with finger contractures for one (1) of 25 sampled residents. Resident #74 Findings Include: Review of the facility policy titled Prevention of Decline in Range of Motion unrevised, revealed under, Policy: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. Record review of the Treatment Administration Record (TAR) revealed an order dated 7/08/24, Caregiver to don (put on) B (bilateral) hand rolls to B (bilateral) hands to decrease risk of skin breakdown and decrease risk of further contracture formation with skin checks/cleanse at the end of each shift to ensure no adverse effects x (times) 7 days a week every shift. The hand rolls were signed as applied/administered on each shift (day, evening, and night) for the dates of 3/3/25 and 3/4/25. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record reviews, and facility policy review, the facility failed to obtain a stop date for as-needed (PRN) psychotropic medications for two (2) of six (6) residents reviewed who were receiving psychotropic medications (Resident #43 and Resident #259). Findings Include: Review of the facility policy titled, Use of Psychotropic Medications, last revised in March 2025, revealed the following under Policy Explanation and Compliance Guidelines: Section 16: Psychotropic medications used on a PRN basis must be limited to no more than 14 days unless the provider determines it is appropriate to extend the order. The medical record must indicate a specific duration. Resident #43 Record review of the Order Summary Report for Resident #43 revealed an order dated 12/06/24 for Ativan (Lorazepam) 1 mg (milligram), to be administered one tablet by mouth every 12 hours as needed for anxiety with no stop date provided. Record review of the admission Record revealed Resident #43 was admitted to 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
Show the remaining 13 citations
  • Potential for harm · D2025-03-06 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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, resident and staff interviews, record review and facility policy review, the facility failed to maintain a medication error rate less than 5% as evidence by the administration of discontinued and incorrectly scheduled medications and failure to administer prescribed medications. This deficient practice was identified in four (4) of 37 medication administration observation opportunities. The medication error rate was 10.81%. This affected Resident #39 and Resident #90. CROSS REFERENCE F658 Findings include: A review of the policy titled Medication Administration revealed the following, Policy: Medications are administered by licensed nurses who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines: Section 10 states that staff must ensure the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e.…

    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 · D2025-03-06 · 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, staff interview, and facility policy review, the facility failed to ensure a medication cart was locked and secured for one (1) of four (4) survey days. Findings Include: Review of the facility policy titled Medication Storage unrevised, revealed, Policy Explanation and Compliance Guidelines . c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. An observation on 3/03/25 at 12:45 PM revealed the medication cart located on C hall was unlocked and unattended without a nurse in view. An observation and interview with Licensed Practical Nurse (LPN) #1 on 3/03/25 at 12:49 PM confirmed she walked away from the medication cart and left it unlocked. She explained that she got called away and forgot to lock it. LPN #1 revealed leaving the medication cart unlocked gave the residents access to the cart and stated, Any of the residents can get in it and take something. An interview with the Administrator (ADM) on 3/04/25 at 10:11 AM confirmed the nurses should…

    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 · D2023-08-24 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview, record review and facility policy review the facility failed to assist a resident with his right to vote for one (1) of five (5) residents reviewed for voting rights. Resident #31 Findings Include: Review of the facility policy titled, Resident Rights with no revision date revealed that each resident had, . A. The right to civil and religious liberties . Review of the facility policy titled, Voting Policy revealed It is a policy of this facility that all residents reserve the right to vote in local, State and Federal elections .If a resident desires to go to the local precinct to vote, transportation arrangements will be made if .and Social Services will be responsible for arranging voting by absentee ballot for any resident who so desires. During the Resident Council meeting on 8/22/23 at 2:00 PM, Resident #31 revealed he has lived at the facility for two years and no one has ever spoke to him about voting, but he would like to. An interview on 8/22/23 at 3:15 PM with…

    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 · D2023-08-24 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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 interviews, record review and facility policy review, the facility failed to notify the Physician or the Nurse Practitioner (NP) of changes in condition for medication administration for a resident for one (1) of nine (9) residents reviewed. Resident #63. Findings include: Record review of facility policy titled, Administering Medications, dated April 2006, revealed, Medications will be administered in a timely manner and as prescribed by the resident's Attending Physician or the facility's Medical Director. The policy also revealed, The Director of Nursing Services and Attending Physician must be notified when two (2) consecutive doses of a medication are refused or withheld. During the record review of Electronic Medical Record (EMAR) for the month of August 2023, it was revealed that Resident #63 did not receive his ordered 8 AM medications for 14 of the 22 days recorded from 8/1/23 - 8/22/23. The reason documented for 13 of the held doses was that the resident was asleep or refused by…

    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 · D2023-08-24 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, record review and facility policy review, the facility failed to provide a follow up to grievances voiced by residents related to laundry services for two (2) of seven (7) residents reviewed during investigations (Resident #37 and Resident #150) and for grievance reported during resident council for one (1) of six (6) residents in attendance, (Resident #93). Findings included: Review of facility policy titled, Resident's Rights, undated, revealed, All nursing home facilities shall adopt and make public a statement of the rights and the responsibilities of the residents residing in such facilities and shall treat such residents in accordance with the provisions of said statement. The statement shall insure each resident of the following: . C. The right to present grievances on behalf of himself, herself, or others to the facility's staff or Administrator, to governmental officials, or to any other person without fear of reprisal and to join with other residents…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-24 · tag F0641 — isolated
    Ensure each resident receives an accurate 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 record review, staff interviews and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessments for a Preadmission Screening Resident Review (PASRR) for Resident #23 and restraint use for Resident #63 for two (2) of 24 sampled residents. Findings include: Record review of facility policy titled, Policy for Completing MDS, dated 10/10 revealed, . The RN (Registered Nurse) Coordinator will check for completeness of assessment by the end date and signed and date. Each person completing sections of the MDS must sign and certify its accuracy . Resident # 23 A record review of Resident # 23's Summary Findings Report, dated 9/21/2020, revealed . Mental Health: .The resident meets criteria for having a diagnosis of mental illness as defined by Preadmission Screening Resident Review (PASRR) . A record review of Resident # 23's annual MDS with Assessment Reference Date (ARD) of 7/28/23 indicated a No to question A1500, which asked if Resident #23 had been evaluated by 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, record review, and facility policy review the facility failed to implement a care plan for fluid restriction for Resident #25, Activity of Daily Living (ADL) care for Resident # 86 and splint application for Resident #91, for three (3) of 27 care plans reviewed. Findings include: Review of the facility policy titled, Comprehensive Care Plan Policy, revealed Policy: It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Resident #25 Record review of the Care Plan, with a problem onset date of 8/2/2022 revealed , At risk for nutritional decline/dehydration r/t . ESRD (end stage renal disease) .fluid restriction .Approaches: NAS (no added salt) LCS (low concentrated sweet) diet with…

    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 before2023-08-24 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, record review and facility policy review the facility failed to provide incontinent care every two hours and as needed for a resident dependent on staff for Activities of Daily Living (ADL) for one (1) of 98 residents reviewed. Resident #86 Findings include: Review of the facility policy titled, Activity of Daily Living Policy with a revision date of 01/2013 revealed Policy Statement: Based on previous evaluations and current data, the nursing staff, in conjunction with Attending Physician, Consultant Pharmacist, therapy staff, and others, will seek to identify the level of care a resident requires for ADL's . An interview on 08/21/23 08:26 AM, with Resident #86 revealed the staff does not always come and change him when he needs it. He stated that he stays in the bed most of the time and sleeps a lot because that is what he prefers. He stated that the staff does not come to change him every two hours and he wished they would come check on him more often than…

    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 before2023-08-24 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, record review, and facility policy the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion as evidenced by staff not applying a hand splint as ordered for one (1) of 41 residents with limited range of motion. Resident #91 Findings include: Review of the facility policy titled, Use of Assistive Devices, dated October 2022, revealed Policy: The purpose of this policy is to provide a reliable process for proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity. Policy Explanation and Compliance Guidelines: A nurse with responsibility for the resident will monitor for the consistent use of the device and safety in the use of the device. An observation on 8/21/23 at 11:00 AM, of Resident #91's right wrist revealed the appearance of a contracture to right wrist area with no device in place. An observation of Resident #91's right…

    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 · D2023-08-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 the facility failed to follow a physician order for a resident who was prescribed fluid restriction for one (1) of nine (9) residents on fluid restriction. Resident #25 Findings include: A review of the policy titled, Fluid Restriction, revealed Fluids will be restricted, originated 9/04, revealed Policy: Fluids will be restricted for residents as directed by physician's orders. The following conditions may require intervention of restricting fluids: .end stage renal disease. Limiting fluids places the residents at high risk for dehydration. Procedure: 1.)Fluids will be distributed to residents placed on fluid restriction in the manner indicated below (Fluid Restriction)1200 cc (cubic centimeter) (Total nursing)360 cc (By Shift 120 cc day 120 cc eve (evening) 120 cc noc (night) Total Dietary) 840 cc (Breakfast) 360 cc (Dinner) 240 cc (Supper) 240 cc.3.)Nursing service will document intake and output. An interview with Resident #25 on 8/21/23 at 2:00 PM, she revealed she was on dialysis and 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-04-14 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, record review and review of the facility policy, the facility failed to provide the necessary services to maintain good grooming and personal hygiene as evidenced by failure to provide nail care and washing of hair for two (2) of nineteen (19) residents observed for Activities of Daily Living (ADL) care. Resident # 76 and # 28. Findings include Review of the facility's policy titled Activities of Daily Living Policy updated July 2014, revealed Based on previous evaluations and current data, the nursing staff .will seek to identify the level of care a resident requires for ADLs .the nursing staff will assess the resident upon admission, quarterly and with significant changes to ensure proper assistance is provided. Resident # 76 On 4/6/21 at 10:13 AM, Resident #76 was up in his wheelchair in his room and his nails were long and dirty. He was asked about his nails and he said they are dirty. On 4/7/21 at 10:35 AM, Resident #76 was up his in wheelchair at 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 · D2021-04-14 · tag F0880 — failed to prevent and control infections — isolated
    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, staff interviews, record reviews and facility policy review, the facility failed to prevent the possible spread of infection for three (3) of 12 residents observed during medication pass and Percutaneous Endoscopic Gastrostomy (PEG) site care, Resident #43, Resident #19 and Resident #78. FACILITY Findings Include: A review of facility's policy,Infection Control Standard Precautions,dated April 2006, revealed that single use items should be properly discarded. On 04/12/21 02:15PM in an observation and interview with LPN, #1 doing Percutaneous Endoscopic Gastrostomy (PEG) tube care on Resident # 43. Resident # 43 was under observation due to leaving the facility with family. LPN #1 stated resident would be under observation until 4/18/21. LPN #1 brought unused supplies of a packet of split gauze spoonges, 100 milliliters (ml) normal saline and wound tape, out of the observation room after completing care. A review of the Physician diagnosis record revealed diagnoses of Dysphagia, Unspecified and Cerebral Infarction dated 9/13/18. A record review of the Quarterly…

    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
  • No harm found · C2023-08-24 · tag F0623 — widespread
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to provide a written notification of transfer to the hospital and/or to the resident and/or the Resident Representative (RR) for three (3) of (3) residents reviewed for hospitalization. Resident # 4, Resident # 33 and Resident # 45. Findings include Resident #4 Record review on facility letterhead dated 8/23/23 from the Administrator revealed, I do not have a current updated policy on Discharge/Transfer Notification. A record review of Resident # 4's nurses notes revealed that she was transferred to the emergency room on 7/18/23 at 4:47 AM related to high blood pressure, respirations, temperature, and low heart rate. A record review of Face Sheet revealed that Resident #4 was admitted to the facility on [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease, unspecified and Acute on Chronic Diastolic (Congestive) Heart Failure. Resident #33 Record review of progress note for Resident #33 dated 8/13/23, revealed, This nurse called…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

$13,757 in federal fines across 1 penalty.

  • $13,757 — penalty dated 2025-03-06

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
MISSISSIPPI BAND OF CHOCTAW INDIANSOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 10/22/1987
FLAKE, BERTAIndividualW-2 MANAGING EMPLOYEEsince 10/16/2019
HALE, SHELLEYIndividualW-2 MANAGING EMPLOYEEsince 02/03/2014
BEN, CYRUSIndividualCORPORATE OFFICERsince 07/09/2019

1 organizational owner 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.

$9.6M
Net patient revenuemost recent cost report
+7.3%
Operating marginrevenue minus expenses
$109K
Related-party expense1% of expenses
Who pays — share of resident-days
Medicaid 87%Medicare 8%Other / private 6%

About 87% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $109K 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

$262per resident / day
operating cost
$7,974per month
≈ monthly operating cost
$283per 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 255339. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-06, 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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