River Heights Healthcare Center
402 Arnold Avenue, Greenville, MS 38701 · For profit - Corporation · 60 certified beds · (662) 332-0318 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
- it has 2 actual-harm citations
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,800 in federal fines (most recent 2024-04-17)
- 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.
| 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.5% | 20.5% | 15.4% | typical |
| Long-stay residents who lose too much weight | 8.9% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.9% | 1.4% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.5% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 1.6% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 1.8% | 0.2% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 0.0% | 3.1% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 12.3% | 19.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 19.7% | 23.8% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 98.4% | 97.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.4% | 6.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 17.5% | 20.7% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.7% | 21.7% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.03 | 2.43 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.24 | 2.86 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 46% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 67% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 60 beds and averages 58.2 residents a day — about 97% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 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 2.70 hrs/resident/day on weekends vs 3.72 on weekdays — 28% thinner on weekends — a notable drop. RN hours go from 0.76 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · Gcited before2024-04-17 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, record review and facility policy review the facility failed follow the person centered care plan to use a full body lift as indicated, causing a dislocated shoulder for Resident #1. This was for one (1) of four (4) resident care plans reviewed. Findings Include Record review of the facility policy titled, Care Plans, Comprehensive, Person Centered with no revision dated revealed Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident . Record review of Resident #1's Care Plan revealed a care plan dated 3/8/23 Alteration in ADLS (Activities of Daily Living) r/t (related to) generalized weakness, difficulty walking, impaired mobility secondary to Hx (history) CVA (Cerebral vascular accident) with left sided Hemiplegia, extensive assist x (times) 2 staff with bed mobility and transfer .Interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-04-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, record review and facility policy review the facility failed to prevent an accident that resulted in an injury, as evidenced by a staff member using a lift the physician had not ordered for one (1) of four (4) residents reviewed that required a lift. Resident #1 Findings Include Review of the facility policy titled, Modified Lifting Policy with no revision dated revealed .Policy Interpretation and Implementation .3. Staff will follow the documented lifting protocol deemed appropriate for each resident. This information is documented in the resident's chart and on the Resident Care Sheet. This information should be referred to prior to lifting/transferring or assisting each resident . An interview and observation on 4/17/24 at 9:10 AM, revealed Resident #1 lying in bed with a total lift sling underneath her. She revealed they now use a lift that lifts her up out of the bed and sits her in her wheelchair. She stated she hurt her shoulder a few weeks ago, but they…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-16 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to ensure residents were free from verbal abuse when a registered nurse used profane, intimidating, and demeaning language toward two (2) of 10 residents reviewed for abuse. Resident #1 and Resident #4.Based on corrective actions taken by the facility on 6/3/26, the State Agency determined the deficiency to be Past Non-Compliance, and the facility was in compliance on 6/4/26 prior to survey entrance on 6/15/26. Findings included:Record review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revealed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse and physical or chemical restraint not required to treat the resident's symptoms .Resident #1Record review of facility investigation regarding an allegation of the verbal abuse of Resident #1 revealed on 5/31/2026…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-07 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 interview, record review and facility policy review, the facility failed to ensure residents were treated with respect and dignity from a staff member for six (6) of eleven (11) residents who attended the Resident Council meeting on 5/5/26. Residents #2, #20, #19, #29, #18, #47.Findings include:A review of the facility policy, Resident Rights, revised October 2025, revealed, Policy Statement .Employees shall treat all residents with kindness, respect, and dignity .A record review of the grievance logs for 2026 revealed no documented concerns related to staff conduct or resident dignity.A record review of the Resident Council meeting minutes for 2026 revealed no documented concerns related to staff conduct or resident dignity.During a Resident Council meeting on 5/5/26 at 2:00 PM, (11) residents were present, all with a Brief Interview for Mental Status (BIMS) score of (15), indicating the residents were cognitively intact. All (11) residents identified Licensed Practical Nurse (LPN) #1 as often being rude during medication administration and general interactions. They…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-07 · tag F0561 — failed to honor residents' choices — patternHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to promote and facilitate resident self-determination by restricting residents' right to freely congregate in the activity room during evening hours for three (3) of eleven (11) residents who attended the Resident Council meeting on 5/5/26. Residents #2, #20 and #40.Findings include:A review of the facility policy, Resident Rights, revised October 2025, revealed, Policy Statement .Employees shall treat all residents with kindness, respect, and dignity .Policy Interpretation and Implementation. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to .exercise their rights as a resident of this facility .f.be supported by the facility in exercising their rights.A record review of the grievance logs for 2026 revealed no concerns documented related to restrictions on resident congregation.A record review of the Resident Council meeting minutes for 2026 revealed no documented concerns related to restrictions on resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-07 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two (2) of (16) sampled residents reviewed (Resident #7 and Resident #9).Findings include:A record review of the facility's Care Plans, Comprehensive Person-Centered with a revision date of March 2022 revealed, A comprehensive person-centered care plan that includes measurable, objective and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident.Resident #7A record review of Resident #7's Care Plan Report revealed an intervention to maintain Enhanced Barrier Precautions (EBP) including washing hands, wearing a gown, wearing gloves, and other precautions when performing close contact care in the resident's room.During an observation on 5/6/26 at 9:20 AM, Licensed Practical Nurse (LPN) #1 was observed administering medication via Percutaneous Endoscopic Gastrostomy (peg) tube to Resident #7. Enhanced Barrier Precaution signage was posted on the door. LPN #1 did not put on 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.
- Potential for harm · E2026-05-07 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review and facility policy review the facility failed to implement physician orders related to colostomy care and suprapubic catheter care for one (1) of (1) care observations. Resident #9Findings Include:A record review of the facility's policy Compliance Risks--Resident Quality of Care and Quality of Life revised January 2025, revealed Compliance with the Medicare and Medicaid Requirements of Participation for resident quality of care and resident quality of life is consistent with the goals of the overall compliance and ethics program .On 5/5/26 at 2:00 PM, during an interview, Licensed Practical Nurse (LPN) #1 stated Resident #9 performs his own catheter care.On 5/5/26 at 3:27 PM, during an interview and observation with Resident #9 stated he performs his own catheter care and colostomy care. He stated the 11-7 nurse brings his colostomy bag to his room around 3:00-4:00 AM daily. He stated he applies three pairs of gloves and removes one pair after each step of care, uses a wet soap towel for catheter care, and wipes from the insertion…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-07 · tag F0697 — failed to manage pain — patternProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review and facility policy review, the facility failed to ensure pain management was provided consistent with professional standards of practice for one (1) of (1) sampled residents reviewed for pain management. (Resident #1).Findings include: A policy review of the Pain Management and Assessment policy no date, reveals, Purpose . The purposes of this procedure are to help the staff identify pain in the resident, develop interventions consistent with the resident's goals and needs, and address the underlying causes of pain .General guidelines. 1. Pain management is a multidisciplinary process that includes the following .monitoring for the effectiveness of interventions; and modifying approaches as necessary .During an interview on 5/4/26 at 1:00 PM, Resident #1 stated he has been experiencing consistent pain at a level of 6 for the last couple of years and that his current pain medication regimen is not strong enough. He stated he has reported this to his medication nurse and to the Nurse Practitioner (NP), who told him it will get better eventually, but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-07 · tag F0851 — patternElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review the facility failed to ensure that complete and accurate direct care staffing information was electronically submitted to the Centers for Medicare & Medicaid Services (CMS) through the Payroll-Based Journal (PBJ) system within the required timeframe for one (1) of four (4) quarters reviewed, FY (Fiscal Year) Quarter 1 2026 (October 1-December 31).Findings Include:A review of the facility policy Reporting Direct Care Staffing Information (Payroll-Based Journal) with a revision date of August 2022 revealed, Direct care staffing information is reported electronically to CMS through the Payroll-Based Journal system. Policy Interpretation and Implementation 1. Complete and accurate direct care staffing information is reported electronically through the PBJ system in a uniform format specified by CMS .10. Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows: Quarter 1 Submission Deadline - February 14th.During an interview…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-07 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review the facility failed to ensure staff adhered to Enhanced Barrier Precaution (EBP) protocols during high-contact resident care activities for one (1) of (1) residents reviewed. (Resident #7)Findings include:A record review of the facility's Enhanced Barrier Precautions with a revision date of 12/2024 revealed Enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug-resistant organisms (MDRO's) to residents .7. a. Gowns and gloves are applied prior to performing the high contact resident care activity (as opposed to before entering the room) .During an observation on 5/6/26 at 9:20 AM, Licensed Practical Nurse (LPN) #1 was observed administering medication via Percutaneous Endoscopic Gastrostomy (PEG) tube to Resident #7. EBP signage was posted on the door. LPN #1 entered the room but did not don (put on) a gown prior to administering medication via PEG tube, as required by the facility's EBP policy and the posted door signage.During an interview on 5/6/26 at 9:54 AM, LPN #1 confirmed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-07 · tag F0867 — failed to act on quality-improvement findings — isolatedSet 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 interview, facility policy review, and record review the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to sustain corrective action to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to ensure infection control standards were adhered to related to proper use of Enhanced Barrier Precautions (EBP) during care in June 2025 and was again cited for the same deficient practice on the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of eight (8) deficiencies cited. F880. Findings included:Record review of the facility policy Quality Assurance and Performance Improvement Program revealed Policy Statement: The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents .Record review of the Centers for Medicare and Medicaid Services (CMS) Form 2567 (Statement of Deficiencies) dated 6/5/2025…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-05 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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, staff interviews, record review, and facility policy review, the facility failed to provide dignity to a resident, as evidenced by leaving an indwelling urinary catheter bag and tubing uncovered for one (1) of three (3) residents with a catheter reviewed. Resident #55 Findings include: A review of the facility policy, Dignity with a revision date of February 2021, revealed .12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: . a. helping the resident to keep urinary catheter bags covered . An observation on 06/03/25 at 7:49 AM, and again at 9:08 AM, revealed Resident #55 lying in his bed in his room. A urinary catheter bag containing 200 milliliters of yellow urine was hanging on his bed and visible from the hall, with no privacy bag in place. During an interview on 6/04/25 at 10:05 AM with Certified Nurse Aide (CNA) #4 and CNA #6, CNA #4 revealed that all urinary catheters are supposed to be kept inside a privacy bag, so the resident's urine is not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · D2025-06-05 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, record review, and facility policy review, the facility failed to notify a resident representative of the risk and benefits for the initiation of a new psychotropic medication for one (1) of two (2) residents reviewed for psychotropic medication use. Resident #31 Findings Include: Review of the facility policy titled Psychotropic Medication Use with a revision date of 2/2025 revealed under, Informed consent or refusal: 1. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: . b. the indications and rationale for the recommendation; c. the potential risk and benefits (including possible side effects, adverse consequences, and the black box warning); and d. the resident's/representative's right to accept or decline the treatment. Record review of Resident #31's Psych Progress Note dated 11/8/24 revealed, Facility request visit due to recent combative behavior. Staff report…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-05 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
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 a safe, homelike environment as evidenced by an unsanitary bathroom for one (1) of the thirty resident shared bathrooms observed. room [ROOM NUMBER], and room [ROOM NUMBER] Findings include: Review of the facility policy titled Safe environment, undated, revealed, The facility must provide- (1) A safe, clean, comfortable, and homelike environment (2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . Review of the facility policy titled Bathrooms, undated, revealed that Bathrooms shall be maintained in a clean and sanitary manner and shall be cleaned on a daily basis. Record review of Grand Rounds for room [ROOM NUMBER] dated 5/27/25, 5/28/25, 5/29/25, 6/2/25, and 6/3/25 revealed that, under Free from urine odors, and bathroom cleaned it was documented No (N). An observation on 6/3/25 at 2:40 PM revealed a strong urine odor in the shared…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-05 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility investigation review, record review and staff interview, the facility failed to protect the residents' right to be free from sexual abuse by other residents for one (1) of six (6) residents reviewed for abuse. Resident #49. Findings included: Record review of the facility policy, titled Abuse Prevention Program, revealed Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Resident #49 Record review of the facility investigation titled Report of Investigation dated 2/24/25, regarding an allegation of sexual abuse involving Resident #52 and Resident #49 revealed that on 2/20/2025 at approximately 5:10 AM Certified Nurse Assistant (CNA) witnessed Resident #52 with his hand underneath Resident #49's blouse rubbing her breasts in the day room. The residents were separated, and Resident #52 was placed on one-on-one monitoring. Resident #49 was assessed and found to have no injuries. Record review of Fact Finding Witness Interview-Confidential, dated 2/20/25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-05 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record reviews and facility policy review, the facility failed to timely submit the quarterly Minimum Data Set (MDS) assessment for one (1) of 22 resident MDS assessments reviewed for timely submissions: Resident #17. Findings include: Record review of the facility policy titled MDS Completion and Submission Timeframes, with revision date July 2017, revealed the following policy statement: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes . Record review of Resident #17's Quarterly MDS assessment with Assessment Reference Date (ARD) of 10/21/2024 revealed, Section Z0500 .B. Date Registered Nurse (RN) Assessment Coordinator signed assessment as complete: 11/14/2024 . Record review of Resident #17's Quarterly MDS assessment with of ARD 4/18/2025 revealed, Section Z0500 .B. Date Registered Nurse (RN) Assessment Coordinator signed assessment as complete: 6/4/2025 . During an interview on 6/4/25 at 1:18 PM with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #49 Record review of Resident #49's care plans revealed an alteration in ADL's related to general weakness , impaired mobility dated 12/26/23 with an intervention of Total Assist times one (1) staff with eating. On 6/3/25 at 7:30 AM an observation revealed Resident #49's breakfast tray was sitting on her bedside table. The resident was lying in bed with her head covered and continued observation revealed that no staff entered the room to assist the resident or set tray up until 8:00 AM. On 6/3/25 at 8:00 AM during interview with CNA #1 she verified that Resident #49 had to be assisted by staff during meals. Interview with Licensed Practical Nurse (LPN) #1 on 6/3/25 at 8:05 AM she confirmed that Resident #49 should have been assisted with breakfast when the tray was delivered. An interview with the Care Plan Nurse at 8:53 AM on 6/5/25 she verified that the care plan should have been followed but wasn't. Record review of the admission Record revealed the facility admitted Resident #49 on 12/20/23 with 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.
- Potential for harm · D2025-06-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #49 An observation on 6/3/25 at 7:30 AM revealed Resident #49's breakfast tray sitting on her bedside table, not opened or set up. The resident was in bed with her head covered with a blanket. Continued observation revealed that staff finally came in to assist the resident with breakfast at 8:00 AM. An interview with CNA #1 on 6/3/25 at 8:00 AM verified that Resident #49 has to be assisted with meals. She revealed that staff know they are not supposed to leave trays in the rooms of residents that need assistance, if they cannot feed them at that time. She stated that if a resident needs to be fed you are supposed to sit down and feed the resident when you bring the tray into the room. She stated that the tray should have been left on the cart until she was available to assist the resident. She verified that the food could get cold and that residents may not want to eat it. An interview with CNA #2 on 6/3/25 at 8:03 AM confirmed that when a meal tray is placed in the room you are to assist the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-05 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
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 provide the necessary foot care to maintain skin integrity and prevent complications for one (1) of three (3) residents reviewed that needed assistance with foot care. Resident #7 Findings Include: Review of the facility policy titled Foot Care with a revision date of 10/2022 revealed under, Policy Statement: Resident receive appropriate care and treatment in order to maintain mobility and foot health. Also revealed under, Policy Interpretation and Implementation: 1. Residents are provided with foot care and treatment in accordance with professional standards of practice. 2. Overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions. On 6/03/25 at 10:28 AM, during an observation and interview with Resident #7 she stated, Are you here to trim my toenails? She revealed her toenails needed cutting and the podiatrist was here weeks…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and facility policy review, the facility failed to provides an environment that is free from accident hazards as evidenced by failure to implement interventions to reduce fall hazards for one (1) of 40 residents sampled, Resident #15. Findings include: Review of the facility policy titled, Safety and Supervision of Residents with a revision date of July 2017 revealed under, Policy Statement .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities .Resident Risk and Environment Hazards .c. Falls. During observations on 6/03/25 at 10:18 AM and again at 2:00 PM, revealed Resident #15 lying in bed with a fall mat folded up and leaning against the wall and without a wedge placed between his thighs. During an observation and interview on 6/4/25 at 11:03 AM, with Certified Nursing Assistant (CNA) #1, she confirmed that the fall mat was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-05 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
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 resident and staff interviews, record review, and facility policy review, the facility failed to ensure an accurate trauma-informed care assessment was completed for one (1) of two (2) residents reviewed for Post-Traumatic Stress Disorder (PTSD). Resident #44 Findings Include: Review of the facility policy titled Trauma Informed Care and Culturally Competent Care with a revision date of 8/2022 revealed under, Purpose: To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Also revealed under, Resident Assessment: 1. Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers . An interview with Resident #44 on 6/04/25 at 1:42 PM revealed he was a United States [NAME] in the military for five (5) years and was a sniper during wartime. He 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.
- Potential for harm · D2025-06-05 · tag F0838 — failed to assess facility resources and resident needs — isolatedConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review and facility policy review, the facility failed to ensure the Facility Assessment was updated to include a comprehensive evaluation of the resident population and the necessary resources, including staffing levels and competencies, required to meet resident needs under both routine and emergency conditions for three (3) of three (3) survey days. Findings include: Review of the facility policy titled Facility Assessment with a revision date of December 2024 revealed Policy Statement: A facility assessment is conducted annually to determine and update the capacity to meet the needs of and competently care for residents during day-to-day operations (including nights and weekends) and emergencies. Facility Assessment .4. The facility assessment is used to inform staffing decisions.A. The facility assessment is used to ensure there is enough staff with appropriate competencies and skill sets to meet the needs of the residents identified through the review of resident assessments and plans of care.(2) Staffing needs are considered for each shift,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-05 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 help prevent the possible transmission of infections when staff failed during medication administration to ensure a multi-use glucometer was properly cleaned and disinfected and failed to use Enhanced Barrier Precautions (EBP) during catheter care (Resident #55) for two (2) of three (3) infection control practices observed. Findings include: Review of the policy titled, Enhanced Barrier Precautions Checklist with no revision date revealed Staff shall apply Enhanced Barrier Precautions to the care of all residents in high contact care activities .5. Barriers include gloves, gowns . An observation of catheter care for Resident #55 on 6/4/25 at 10:05 AM revealed Enhanced Barrier Precautions (EBP) signage on the outside of the room door. Certified Nurse Aide (CNA) #4 entered the room, performed hand hygiene, applied clean gloves, and did not apply a gown for enhanced barrier precautions. The Lead CNA assisted CNA #4 with catheter care and washed her hands, applying gloves, but did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-16 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 staff and resident interview, record review and facility policy review the facility failed to prevent resident to resident sexual abuse for two (2) of five (5) residents reviewed for sexual abuse. Resident # 1 and Resident #3. Findings include: Record review of the facility policy, titled Abuse Prevention Program dated November 2010, revealed Policy Statement: Our residents have the right to be free from abuse .1. Our facility is committed to protecting our residents from abuse by anyone including .other residents . Record review of the facility investigation titled Checklist for Follow-Up to Incidents Requiring Investigation dated 7/10/24 regarding an allegation of sexual abuse involving Resident #1 and Resident #2 revealed that on 7/6/24 at 7:16 PM, Resident #4 reported that he saw Resident #1 touching Resident #2's breast under her shirt. He stated that he told him to stop and went out to smoke. Resident #4 stated upon his return Resident #1 was touching Resident #2 on her breast again, so he went to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-21 · tag F0641 — isolatedEnsure 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 and Resident Review (PASRR) for two (2) of 16 sampled residents. Resident #4 and Resident #15. Findings Include: A record review of the facility policy Certifying Accuracy of the Resident Assessment, revised December 2009 revealed Policy Statement: All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment . Resident #4 A record review of Resident #4's annual MDS with a Assessment Reference Date (ARD) of 5/26/2023, indicated a No to A1500, Is the resident currently considered by the state level II PASRR process to have serious mental illness . A record review of Resident #4's Summary Findings Report, dated 10/20/2022, revealed . Mental Health: .The resident meets criteria for having a diagnosis of mental illness as defined by Preadmission Screening Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2023-11-21 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review and facility policy review the facility failed to submit a Discharge Minimum Data Set (MDS) assessment timely in accordance with the current federal and state submission timeframes for one (1) of 16 resident MDS assessments reviewed. Resident #40 Findings include: A review of the facility policy titled, MDS Completion and Submission Timeframes revised September 2010 revealed, Policy Statement: Our facility will conduct and submit resident assessments in accordance with the current federal and state submission timeframes. Policy Interpretation and Implementation: . 2. The following timeframes will be observed by the facility: Assessment type: .Discharge Assessment .Transmission Date: MDS Completion Date +(plus) 14 calendar days . Record review of the Discharge MDS assessment for Resident #40 revealed the resident was discharged [DATE]. Section Z revealed Section K Swallowing /Nutritional Status was completed on 11/16/23. A review of the MDS transmission reports from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,800 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $8,800 — penalty dated 2024-04-17
- Medicare payment denial — starting 2024-05-16 for 12 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| DASPIT, RICHARD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/17/2014 |
| JOYCE, KIMBERLY | Individual | CORPORATE OFFICER | since 08/02/2021 |
| PEELER, LONNIE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2014 |
| CARTER, ISLEY | Individual | ADP OF THE SNF | since 06/16/2025 |
| HODGES, COLE | Individual | ADP OF THE SNF | since 06/16/2025 |
CMS files one row per role, so the 8 rows in the source record cover these 5 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.
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 $362K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Mississippi Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 255217. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, 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 →
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