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Greenbriar Nursing Center

4347 West Gay Road, Diberville, MS 39540 · For profit - Corporation · 103 certified beds · (228) 392-8484 Medicare & Medicaid certified

Call the home — (228) 392-8484 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Nov 20242 actual-harm citations CMS recorded as corrected before the inspection ended (past non-compliance)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 2 serious findings 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 (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • 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) 3 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3920 Promenade Pkwy, Suite A · (228) 456-0173 · Call to confirm hours
Pharmacy
3867 Promenade Pkwy · (228) 233-3302 · Call to confirm hours
Grocery
3615 Sangani Blvd · (228) 229-0042 · Call to confirm hours
Park
11288 Lamey Bridge Rd · 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 3 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 increased40.4%20.5%15.4%worse
Long-stay residents who lose too much weight4.3%6.2%5.4%better
Long-stay residents with a catheter left in their bladder2.2%1.4%0.9%worse
Long-stay residents with a urinary tract infection1.0%2.5%2.0%better
Long-stay residents with depressive symptoms10.0%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 injury1.0%3.1%3.3%better
Long-stay residents whose ability to walk worsened28.8%19.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication25.7%23.8%18.9%worse
Long-stay residents given the seasonal flu vaccine91.8%97.0%95.3%typical
Long-stay residents with pressure ulcers3.6%6.3%4.7%better
Long-stay residents with worsening bladder/bowel control32.5%20.7%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table22.2%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%2.5%1.4%better
Short-stay residents given the seasonal flu vaccine66.7%84.6%79.4%worse
Short-stay residents rehospitalized after admission28.3%27.7%22.6%worse
Short-stay residents with an outpatient ER visit13.8%15.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.612.431.67typical
Long-stay outpatient ER visits per 1,000 resident days2.822.861.80worse

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.

47.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 166 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

47.5%U.S. median 51.5%
Got home and stayed home
11.8%U.S. median 10.7%
Went back to hospital
52.2%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 52.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 69 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 SNF47.5%CMS range 40.8–54.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.8%CMS range 8.5–16.010.7%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 discharge52.2%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 discharge58.0%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 discharge46.4%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 identified99.0%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 setting94.6%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 discharge100.0%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 worsened1.9%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 hospitalization8.6%CMS range 5.4–12.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.011.02Oct 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

0.35
RN hours/ resident / day
1.14
LPN hours/ resident / day
2.29
Aide hours/ resident / day
3.78
Total nurse hours/ resident / day
0.23
RN hoursweekends
49.5%
Total nursing turnover
54.5%
RN turnover

How full it usually is: this home is certified for 103 beds and averages 88.7 residents a day — about 86% occupied, or roughly 14 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 3.78 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.29 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 3.34 hrs/resident/day on weekends vs 3.96 on weekdays — 16% thinner on weekends. RN hours go from 0.40 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% 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

4
deficiencies at the latest standard inspection (2025-06-12)
3
at the previous standard inspection (2024-02-08)

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.

17 citations, most serious first. The 12 most serious are shown; the remaining 5 are one tap away and print in full.

  • Actual harm · Gcited before2026-03-19 · 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 interview and record review, the facility failed to implement the comprehensive person-centered care plan requiring two (2) staff to assist with bed mobility, when staff provided care without the required assistance, resulting in the resident falling from the bed and sustaining a proximal humeral fracture (a break in the upper arm bone near the shoulder) for one (1) of three (3) sampled residents (Resident #1) .Findings include:A record review of the Care Plan Report revealed Resident #1 had a focus of an ADL (activities of daily living) self-care performance deficit with interventions initiated on 7/14/25 that included, BED MOBILITY: The resident requires x (times) 2 staff to turn and reposition in bed.A record review of the facility's investigation revealed that on 2/11/26 at 10:05 PM, Certified Nursing Aide (CNA) #1 was providing in-bed care to Resident #1, including a linen and brief change. During care, the resident rolled to assist and subsequently rolled too far, exiting the bed and landing on the floor.A record review of the Incident Witness Statement, dated…

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

    Resident Assessment and Care Planning Deficiencies · Past Non-Compliance
  • Actual harm · G2026-03-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a resident was free from accident hazards during bed mobility when a Certified Nursing Aide (CNA) performed a linen and brief change without the required two (2) person assistance, in which Resident #1 fell from the bed and sustained a proximal humeral fracture (a break in the upper arm bone near the shoulder) for one (1) of three (3) residents reviewed for accidents.Findings include:A record review of the facility's investigation, undated, revealed that on 2/11/2026, at approximately 10:05 PM, CNA #1 was providing in-bed care to Resident #1, including a linen and brief change. During care, Resident #1 rolled to assist. She subsequently rolled too far and exited the bed, landing on the floor. A record review of the Incident Witness Statement, dated 2/11/26 and signed by CNA #1 revealed a Narrative if incident if witnessed which indicated the CNA was changing the resident and went to pull the sheet from under her and the resident rolled and fell. The CNA documented, .the brief was already on her, and I…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · E2026-05-26 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and facility policy review, the facility failed to revise care plans to accurately reflect residents' infection control status for two (2) of three (3) residents reviewed for infection control. Resident #1 and Resident #3Findings include:A review of the facility's policy, Care Plan Revisions Upon Status Change, dated November 2024, revealed, .to provide a consistent process for reviewing and revising the care plan. Policy Guidelines.1. care plan will be reviewed, and revised as necessary. 2. Procedure for.revising the care plan.d.care plan will be updated with the new or modified interventions. f.Care plans will be modified as needed. h.to ensure care plans have been updated to reflect current resident needs.Resident #1A record review of Resident #1's Care Plan Detail revealed an individual care plan with focus Resident has active diagnosis ESBL (Extended-Spectrum Beta-Lactamase) UTI (Urinary Tract Infection) dated 4/26/26. The goal revealed Resident's symptoms will be managed and ESBL will be resolved. The Interventions/Tasks 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-10 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' right to a clean, comfortable, and homelike environment as evidenced by adequate clean linens and washcloths were unavailable for resident care for one (1) of two (2) survey days.Findings include:A review of the facility's policy, Resident Rights, revised February 2023, revealed, .The resident has the right to a dignified existence.8. Safe environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including.treatment and supports for daily living safely .On 2/9/26 at 10:50 AM, during an observation and interview with the facility owner, linen closets, supply closets, and nurses' station supply rooms were observed. The linen closet on Beach Avenue Hall was observed to contain no towels, washcloths, fitted sheets, blankets, or bed linen pads. Only one item was observed in the linen closet. The owner reported the closets would be filled once laundry staff made rounds.On 2/9/26 at 12:21 PM, during an interview, Certified Nursing…

    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 before2025-06-12 · 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 observation, interview, record review, and facility policy review, the facility failed to ensure perineal care was provided in a manner to prevent the possible spread of infection when a Certified Nurse Aide (CNA) failed to perform hand hygiene during care for one (1) of four (4) residents observed for care, Resident #22. Findings included: A review of the facility's Hand Hygiene Policy, dated 8/23, revealed, .The facility considers hand hygiene the primary means to prevent the spread of infections. All staff will perform proper hand hygiene procedures to prevent the spread of infection .Policy 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 6/12/25 at 10:34 AM, during an observation of perineal care provided by Certified Nurse Aide (CNA) #2, she began to assist Resident #22 and then stated, I need some help. She removed her gloves and exited the room without performing hand hygiene. She returned, did not perform…

    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 · D2025-06-12 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, the facility failed to maintain privacy during the provision of perineal care for one (1) of four (4) residents observed for care, Resident #22. Findings included: A review of the facility's policy titled Resident Rights, dated 2/2023, revealed, The resident has the right to a dignified existence .7. Privacy and confidentiality. The resident has a right to personal privacy . On 6/12/25 at 10:34 AM, during an observation of perineal care provided by Certified Nurse Aide (CNA) #2, the CNA left the resident exposed while she exited the room to get assistance. Resident #22 remained exposed and was pulling at her shirt in an attempt to cover her private area. CNA #2 returned with CNA #1, then later left the room again to retrieve additional towels, once again leaving Resident #22 exposed. The resident continued to pull her shirt down while waiting. On 6/12/25 at 10:59 AM, during an interview with lead CNA #1, she confirmed Resident #22 was left exposed and stated it was a dignity issue. She noted that 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 · D2025-06-12 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, and facility policy review the facility failed to ensure the protection of privacy and confidentiality of resident care information when clinical instructions were posted in public view without safeguards for one (1) of eighteen (18) sampled residents, Resident #78. Findings included: A review of the facility's policy Resident Rights, dated 02/2023, revealed, .7. Privacy and confidentiality. The resident has the right to personal privacy and confidentiality of his or her . medical records .a. Personal privacy includes .medical treatment .b. The resident has a right to secure and confidential personal and medical records . On 6/10/25 at 12:32 PM, during an observation, a sign indicating NPO (Nothing by Mouth) was observed posted on the outside of Resident #78's door, in plain view from the hallway. On 6/12/25 at 8:45 AM, during an interview with the Director of Nursing (DON), she stated the signage was posted so staff would know the resident was not to be given anything by mouth. She also stated she was unsure if the resident's…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · 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 provide Percutaneous Endoscopic Gastrostomy (PEG) care in a manner to prevent the possible spread of infection during an annual recertification survey on 2/8/24 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 four deficiencies cited. F880. Findings include: Record review of the facility's QAPI Change Process Policy (undated) revealed, .The facility has established and utilized a systematic approach to performance improvement activities to ensure changes are effective and improvements are sustained or modified as needed . Record review of the Provider History Profile revealed the facility received a citation for F880-Infection Control. Record review of the CMS-2567…

    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 · D2024-11-12 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, record review, and facility policy review, the facility failed to report an allegation of sexual abuse within two (2) hours, as required, when Resident #1 verbalized she was sexually abused for one (1) of three (3) sampled residents. Findings included: A review of the facility's, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation Policy, revised in August 2023, revealed, It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment .immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations with prescribed timeframes . Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation . Any owner, operator, employee, manager, agent, or contractor of the facility can report an allegation of abuse/neglect/exploitation to the abuse agency hotline . A record review of the admission Record revealed the facility admitted Resident #1 on 09/13/2024 with diagnoses including Dementia and Alzheimer's Disease. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-08 · 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 observation, staff interview, record review, and facility policy review, the facility failed to provide peg tube care (Resident #29) and catheter care (Resident #61) in a manner to prevent the possible spread of infection for two (2) of five (5) resident care observations. Findings Include: Review of the facility's Gastrostomy Site Care Policy, dated 10/23, revealed, Policy: It is the policy of this facility to perform gastrostomy site care as ordered. Policy Guidelines .14. Using soap and water/wound cleanser gently clean the area around the tube and continue in an outward circular fashion, ensuring that under the bolster is cleaned . Review of the facility's Hand Hygiene Policy, dated 8/23, revealed, Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. All staff will perform proper hand hygiene procedures to prevent the spread of infection to .residents .Policy Guidelines .6. Additional considerations: 1. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning…

    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 before2024-02-08 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain a comfortable room temperature levels of 71 degrees to 81 degrees Fahrenheit (F) for two (2) of 18 sampled residents. Resident #13 and Resident #9 Findings include: A review of the facility's Safe and Homelike Environment Policy dated Apr (April) 23 revealed Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment . Policy Guidelines: 7. The facility will maintain comfortable and safe temperature levels . Resident #13 On 02/05/24 at 12:53 PM, during an observation and interview with Resident #13, the resident complained the room temperature was too cold for him. He stated had had complained to all the staff about the room temperature, but nothing had been done. There was no unit or thermostat in the room for the resident to be able to adjust the temperature. On 02/08/24 at 9:52 AM, during a phone interview with Resident #13's wife, she explained the resident had…

    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 · D2024-02-08 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review, and the facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) related to restraints for two (2) of 18 sampled residents. Resident #30 and Resident #36 Findings Include: A review of the facility's MDS 3.0 Completion Policy, dated October 2023, revealed, Policy Statement: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan .Policy Guidelines .4. Care Plan Team Responsibility for Completion go MDS Sections .a. ii. Persons completing .the assessment must attest to the accuracy of the section they completed . Resident #30 During an observation on 2/5/24 at 1:35 PM, Resident #30 was observed to have one full length bedrail on one side of the bed and 1/4 (quarter) length side rail on the other. He stated that he requested the long bedrail to be up at night, and he kept it down during the day to make it easier to get out of the bed. A record review of the admission Record revealed the facility admitted Resident #30…

    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
Show the remaining 5 citations
  • Potential for harm · D2021-11-04 · tag F0623 — isolated
    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 interviews and record review, the facility failed to ensure two (2) of two (2) sampled residents received written notice of transfer to the hospital. Resident # 23 and Resident # 67. Findings include: Resident #23 During an interview on 11/03/21 at 08:50 AM, with the Administrator, stated on admission the family signs a bed hold policy and when a resident is transferred to the hospital the nurse will fill out the form. The form is sent with the resident to the hospital. The family gets the sheet when the resident arrives at the hospital. The Administrator confirmed the facility does not mail letters to the family/representatives explaining why the resident was transferred to the hospital. The Administrator said the facility emails the resident representative when the resident is sent to the hospital. The Administrator also confirmed the facility did not have a Transfer Policy. On 11/03/21 at 4:00 PM, during a phone interview with Resident #23's Representative, she explained at the time her mother…

    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 before2021-11-04 · 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, staff interviews, record review and facility policy review the facility failed to follow the care plan related to catheter/incontinent care and failed to develop an approach for securing a catheter tube for two (2) of 19 care plans reviewed, Resident #35 and Resident #117. Findings Include: Record review of the facility's policy, Comprehensive Care Plans, dated September 2018, it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified assessment in the resident's comprehensive assessment. Resident #35 On 11/3/21 at 9:55 AM. an observation of catheter care by Certified Nursing Assistant #3 (CNA) and assisted by CNA #4 revealed CNA #3 did not change gloves after setting up supplies. She used gloved hands to close the curtain and did not change gloves and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-11-04 · 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, staff interviews, record review and facility policy review the facility failed to provide catheter/incontinent care in a manner to prevent infection and trauma to the meatus during catheter/incontinent care for two (2) of three (3) catheter care observations Resident #35 and Resident #117. Findings include: The facility policy, Catheter Care Policy, dated October 2018 revealed, Policy: The purpose of this procedure is to prevent catheter-associated urinary tract infections .Policy Explanation and Compliance Guidelines: 9 .Wipe from front to back with a clean cloth moistened with water and perineal cleanser (soap). Use a new part of the cloth or different cloth for each side. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter . The facility policy, Perineal Care Policy, dated October 2018 revealed, Policy: It is the practice of the facility to provide perineal care to all…

    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 · D2021-11-04 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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, the facility failed to ensure food was served at a palatable and satisfactory temperature for five (5) of twelve (12) residents interviewed in Resident Council. (Residents #16, #26, #38, #42, and #53) Finding Include: On 11/02/21 at 2:00 PM, during Resident Council meeting, residents complained of receiving cold food if they decide to eat in their rooms and not in the dining area. The residents explained that all three meals have been served cold in their rooms. Residents explained they have talked about food being cold in previous resident council meetings and have made the Social Worker aware of the cold food. At 3:00 PM on 11/02/21, during an interview with Social Worker, she explained she does attend the resident council meetings monthly at the request of the residents and takes the meeting minutes. She confirmed the residents did have complaints about the food being served cold. On 11/03/21 12:00 PM State Survey Agency (SSA) observed Dietary #2 and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-11-04 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility policy review, the facility failed to prevent the possible spread of infection while providing incontinent care for two (2) of three (3) observations. Resident #35 and Resident #45. Findings Include: Record review of the facility's policy, Hand Hygiene Policy, dated March 2020, revealed, Policy: The purpose of this policy is to provide guidelines for proper hand hygiene to prevent spread of infection to other personnel, residents, and visitors. Policy Guidelines: All facility personnel must perform hand hygiene for at least 20 seconds under the following conditions: .8. Before handling clean or soiled dressings/linens/etc. 9. Before performing resident care procedures .11. After handling soiled dressings/linen, contaminated equipment, etc. 12. After contact with blood, body fluids, excretions, secretions, mucous membranes, or non-intact skin. 13. After handling items potentially contaminated with blood, body fluids, secretions, or excretions. Record…

    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

“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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
CAIN, AVONNAIndividualDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; ADP OF THE SNFsince 07/04/2010
ASHLEY, HEATHERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/24/2023
JOHNS, STEPHENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2007

CMS files one row per role, so the 8 rows in the source record cover these 3 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.

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.

$8.5M
Net patient revenuemost recent cost report
+12.6%
Operating marginrevenue minus expenses
$165K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 62%Medicare 18%Other / private 20%

This home reported $165K 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

$287per resident / day
operating cost
$8,727per month
≈ monthly operating cost
$329per 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 255323. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-12, 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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