Crystal Rehabilitation And Healthcare Center
902 Sgt John A Pittman Drive, Greenwood, MS 38930 · For profit - Corporation · 100 certified beds · (662) 453-9173 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2023
- it has 1 actual-harm citation
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,788 in federal fines (most recent 2025-12-09)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- 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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 | 23.9% | 20.5% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.8% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.6% | 1.4% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.7% | 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 | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.4% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 31.7% | 19.6% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 8.4% | 23.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.0% | 6.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.9% | 20.7% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.0% | 21.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 2.5% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 68.2% | 84.6% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 29.4% | 27.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 22.5% | 15.5% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
62.0% 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 49 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 62.0%CMS range 46.9–77.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 6.9–15.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 9.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 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 | 0.84 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 100 beds and averages 75.4 residents a day — about 75% occupied, or roughly 25 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.99 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.56 is at or above 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 3.71 hrs/resident/day on weekends vs 4.10 on weekdays — 10% thinner on weekends. RN hours go from 0.70 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% is below 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
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.
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.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2025-12-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review and facility policy review, the facility failed to ensure timely assessment, physician notification, and initiation of appropriate treatment for an identified pressure ulcer to prevent further deterioration and promote healing for one (1) of three (3) residents reviewed for pressure ulcers. Resident #1.Findings Include:Record review of facility policy The [Proper Name of Corporation] Skin Integrity Prevention and Treatment Program revealed .Weekly Skin Integrity Checks a. Weekly assessment looking for new wounds-completed by a licensed nurse; b.Document on/in Treatment Record; c. If new area found .Notify Medical Doctor (MD) -obtain treatment orders .Record review of a Progress Note dated 1/17/25 documented by Licensed Practical Nurse #1 (LPN #1) revealed Resident #1 was noted with an open wound to the left upper extremity below the elbow with sanguineous drainage present. The note indicated first aid treatment was initiated and that the oncoming nurse and treatment nurse would be notified; however, there was no documentation to support that 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 · F2024-10-24 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
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 ensure there was an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by repeat deficiencies for Activities of Daily Living (ADL) F677 over the last three annual surveys. Findings Include Review of the facility policy titled, (Proper facility name) QAPI Program with no revision date revealed under the Purpose Statement .The purpose of Quality Assurance Performance Improvement committee is to create a system for improving the care for our residents . An interview on 10/24/24 at 10:54 AM with the Corporate Nurse revealed the QAPI committee met with all department heads after the last survey in 6/2023, in 7/23 they met and went over anything that was trending based on the monitoring that was put into place after the survey that resulted in deficiencies and in 9/23, they went back to reviewing normal stuff. She stated that monitoring was supposed to have continued for the deficiencies from the last survey, but she is not sure that it did. She revealed that she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-10-24 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review and facility policy review, the facility failed to inform staff and visitors of residents that were in Transmission-Based Precautions (TBP) for six (6) of six (6) positive COVID-19 residents reviewed. Residents #6, #28, #29, #38, #81, and #84. Cross Reference F882 Findings Include: Record review of the facility policy titled, COVID-19 Policy and Procedures with a revision date of 9/15/23 revealed under, Training: Signage should be posted describing ways to prevent the spread of germs and protect against COVID-19 virus. This record review revealed under Core Principles of COVID-19 Infection Prevention .Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, and other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene) and appropriate staff use of Personal Protective Equipment (PPE). 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 · F2024-10-24 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, record review and facility policy review, the facility failed to ensure the Infection Preventionist fully implemented the Infection Control Program, as evidence by failure to ensure signage was applied to resident's rooms that were under Transmission-Based Precautions and complete surveillance for the current COVID-19 outbreak for one (1) of three (3) days of survey. Cross Reference F880 Findings Include: Record review of the facility policy titled, COVID-19 Policy and Procedures with a revision date of 9-15-23 revealed under, Training: Signage should be posted describing ways to prevent the spread of germs and protect against COVID-19 virus .Core Principles of COVID-19 Infection Prevention .Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, and other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene) and appropriate staff use of Personal Protective Equipment (PPE). An…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interview, record review and facility policy review, the facility failed to implement an Activities of Daily Living (ADL) care plan for a resident that was dependent on staff for nail care and shaving (Resident #11, #13, #47, #51) and failed to implement a care plan for a resident requiring a hand splint (Resident #62) for five (5) of 29 care plans reviewed. Findings Include A review of the facility policy titled, Care Pans, Comprehensive, Person-Centered, revealed, 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 . Resident #11 - Cross Reference F677, F687 Record review of the Care Plan for Resident #11 revealed I have Diabetes Mellitus . Interventions, Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails .Diabetic Nail care weekly per nurse. During an observation and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-24 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide personal hygiene for four (4) of 26 sampled residents as evidenced by failure to provide nail care (Resident #11, #13, #47, and #51) and shave a resident (Resident # 47). Findings Include: Review of the facility policy titled, Activities of Daily Living (ADL) Supporting with a revision date of March 2018 revealed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Resident #11- Cross Reference F687 An interview and observation on 10/22/24 at 10:05 AM with Resident #11 revealed the resident is non-verbal but indicated that she does not receive toenail care. The resident pulled off her left sock and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-24 · 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 observations, staff interviews, record review and facility policy review, the facility failed to ensure that residents' dignity was not compromised as evidence by Multi Drug Resistant Organism (MDRO) signs on resident's doors for 12 of 96 residents reviewed for dignity. Findings Include: Record review of the facility policy titled, Resident Rights with a revision date of 1/11/24 revealed that .Resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside Facility. Facility must protect and promote the rights of each resident, including each of the following rights: 1. Exercise of Rights .c. Resident has the right to be treated with dignity and respect for the personal integrity of the individual . An observation on 10/22/24 during initial tour of the resident doors in the facility revealed there were MDRO signs on the doors of the following rooms: 110, 111, 122, 125, 128, 132, 208, 215, 218, 223, 225, and 228. An interview and observation on 10/23/24 at 8:45 AM, with Registered Nurse (RN) #1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-24 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff and resident interview, record review and facility policy review, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNOC) was provided for two (2) of three (3) residents reviewed for beneficiary notices. Resident A and Resident B. Findings included: Review of the facility policy Form Instructions for the Notice of Medicare Non-Coverage (NOMNOC) CMS-10123 revealed When to deliver the NOMNOC, A Medicare provider .must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNOC) to beneficiaries/enrollees receiving covered skilled nursing .services. The NOMNOC must be delivered at least two calendar days before Medicare covered services end . A completed Beneficiary Protection Notification Review was provided by the Business Office Manager (BOM) on 10/22/24 at 2:05 PM, that indicated Resident A had a Medicare Part A stay from 6/7/24 through 7/19/24, and Resident B had a Medicare Part A stay from 6/14/24 through 6/21/24, with no supporting documentation, such as a NOMNOC or Advanced Beneficiary Notice (ABN). An interview on 10/23/25 at 8:05…
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 before2024-10-24 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and facility policy review the facility failed to secure electronic health records as evidenced by an Electronic Medication Administration Record (EMAR) visible while the medication cart was unattended on the East Short Wing medication cart for one (1) of three (3) medication carts. Resident #13 Findings Include: Review of the facility policy titled, Resident Rights with a revision date of 1/11/24 revealed, 12 . Privacy and Confidentiality. Resident has the right to personal privacy and to confidentiality of his/her personal and clinical records. An observation on 10/23/24 at 8:05 AM, of a computer that was located on an unattended medication cart on the East Short Wing revealed the computer was opened with Resident #13's EMAR information visible on the screen and the screen was visible to anyone passing by the cart. The visible information included Resident #13's name, medications, and room number. An interview on 10/23/24 at 8:08 AM, Registered Nurse (RN)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-24 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident and staff interview, and facility policy review, the facility failed to maintain housekeeping and maintenance services necessary to maintain a sanitary and comfortable resident environment, as evidenced by flies in residents room (Resident # 2 and Resident #7), dirty sheet and leaking air conditioning unit (Resident # 13), a dirty personal fan (Resident # 29) and a dirty floor and foul odor in resident's room (Resident # 86) for five (5) of 25 sampled residents. Findings Include: Review of the facility policy titled, Building Inspections undated, revealed under, Policy: Conduct routine building inspections on a monthly basis to identify potential problems and perform any required maintenance. Review of the facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment with a revision date of 3/23, revealed under, Policy Interpretation and Implementation: c . (3) . Disinfection is performed with an EPA (Environmental Protection Agency)-registered disinfectant labeled for use in healthcare settings. A review of a letter on company…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-24 · 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 staff interview, record review, facility policy review, and Resident Assessment Instrument (RAI) review, the facility failed to ensure that the Minimum Data Set (MDS) was coded accurately for four (4) of 26 sampled residents. Resident #13, # 47, 56, and #62. Findings Include: Review of the facility policy titled, MDS Coding Policy with a revision date of January 4, 2023, revealed, Proper facility Name affiliated facilities utilize the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately. Resident #13 Record review of the MDS with an Assessment Reference Date (ARD) of 8/12/24 revealed that Resident #13 is taking an anticoagulant medication and was not taking an antiplatelet. Record review of the August 2024 Medication Administration Record (MAR) revealed that Resident #13 did not receive anticoagulant medications for the month of August but did receive Aspirin (ASA) An interview with the Registered Nurse…
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 16 citations
- Potential for harm · D2024-10-24 · 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
Based on observations, resident and staff interviews, record reviews and facility policy review, the facility failed to ensure foot care was completed for one (1) of four (4) sampled residents. Resident #11. Cross Reference: F 677 Findings Include: Record review of Foot Care policy revised October 2022 revealed Policy Statement, Residents receive appropriate care and treatment in order to maintain mobility and foot health. Policy Interpretation and Implementation, 1. Residents are provided with foot care and treatment in accordance with professional standards of practice .3. Residents are assisted in making appointments with .specialists (podiatrist, endocrinologist, etc.) as needed. 4. Trained staff may provide routine foot care (e.g. toenail clipping) within professional standards of practice . On 10/22/24 at 10:05 AM, during an observation and interview with Resident #11 she removed her left sock and shoe and pointed to her left great toe, which was one-half inch (1/2) long and jagged. Resident #11 expressed a desire to have her toenails trimmed and indicated that she had 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.
- Potential for harm · Dcited before2024-10-24 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, record review and facility policy review, the facility failed to provide the services, care, and equipment to assure a resident maintained, and improved to his/her highest level of range of motion (ROM) and mobility for one (1) of five (5) residents for positioning and mobility reviewed. (Resident # 62). Findings include: A review of the facility policy titled, Contracture Management Program, revealed, Intent: To have a program within the facility geared towards the prevention of new contractures and maintenance or improvement of Range of Motion . An observation on 10/22/24 at 10:15 AM revealed Resident #62 to have a left-hand contracture with no splinting device in use, and no device observed in the resident's room. In an interview with Resident #62, he revealed that the staff did not put anything on his hand. A review of the physician's order for Resident #62 dated 2/23/24, revealed Staff to apply (L) left-hand splint before breakfast and remove after dinner daily for eight (8) hours wear as tolerated and provide skin hygiene before and after…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-24 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and facility policy review, the facility failed to maintain an effective pest control regimen against flies as evidenced by fly sightings in a resident room for two (2) of 89 residents. Resident #2, and #7. Findings Include: Cross-Reference F584 Review of the facility policy titled Pest Control undated, revealed under, Policy: Conduct pest control by an outside vendor on a routine basis to maintain the Community in a safe and sanitary condition. Also, revealed under, Procedures: 1. Perform pest control on a consistent basis to ensure that the building is maintained in a pest-free condition. On 10/22/24 at 9:50 AM, an observation of Resident #7 revealed, the resident lying in his bed with the cover over his head. Further observation revealed that there were eight (8) flies on top of the bed spread and two (2) on the privacy curtain. On 10/22/24 at 9:56 AM, an observation of Resident #2 (roommate to Resident #7) revealed the resident was lying in his bed with the cover pulled up over his head. Further observation revealed 4 flies on the bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-26 · 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 record review, staff interview, and facility policy review, the facility failed to provide adequate supervision and monitoring to reduce the risk of accident and hazards for a cognitively impaired ambulatory resident for (1) one of (4) four residents reviewed for accidents. (Resident # 1) Findings include: Review of the facility policy titled, Safety and Supervision of Residents, dated July 2017 revealed 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. Systems approach to safety: 2.) Resident supervision is a core component of the system approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment . 3.) The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may…
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 · D2023-09-14 · 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 staff interviews, resident interview, facility policy review, and record review, the facility failed to ensure residents were free from abuse/neglect, as evidenced by a Certified Nursing Assistant (CNA) not performing needed hygiene care, being rough during care and cursing around residents, for four (4) of 10 residents that were provided care by CNA #5. Resident #1, Resident #2, Resident #3, and Resident #4. Findings include: Review of the facility policy titled Abuse Prohibition Policy, with a review date of 3-2023, revealed INTENT: This protocol was intended to assist in the prevention of abuse, neglect . Each resident has the right to be free from abuse, mistreatment, neglect . POLICY: 1. The facility will prohibit neglect, mental or physical abuse . Record review of the Investigation Summary revealed This is a written investigation summary to follow up on an allegation reported 08/27/2023 .Resident Statement of Events &/or Timeline of Events: On 08/27/2023, LPN #1 (Formal Name) alleged that she witnessed (Formal Name) CNA #5 being aggressive and rude to (Formal Name)…
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 · D2023-05-25 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interviews, facility policy review and record review the facility failed to resolve grievances in a manner that would prevent them from reoccurring as evidenced by ongoing resident complaints regarding not receiving ice water for four (4) of 86 residents reviewed during survey. Resident 32, 33, 45 and 62 Findings Include: Record review revealed a typed statement on facility letterhead dated 5/24/23 that revealed the facility did not have a policy regarding unresolved grievances and was signed by the Administrator. Record review of the facility policy titled, Hydration Management with a revision date of January 2023 revealed, .Procedure .Hydration passes three times a day (approximately 10 AM, 2 PM and 7 PM) whereby all residents will be offered beverage. The total volume of fluids offered at each hydration pass will be approximately 4 oz's. During the resident council meeting on 5/23/23 at 2:30 PM, Residents #32, #33, #45 and #62 revealed that they have complained about not getting…
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 before2023-05-25 · 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
Based on observation, staff and resident interviews, record review, and facility policy review the facility failed to Implement a care plan for Activities of Daily Living (ADL) care Resident #3 , PEG (percutaneous endoscopic gastrostomy) tube medication administration (Resident # 77) and tube feeding (Resident #238) for three ( 3) of 18 residents reviewed. Resident #3, #77 and #238. Findings include: Record review of the facility policy titled Care Plans, Comprehensive Person-Centered dated 10/22 and revised on 1/23 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. 8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; . Resident #3 Review of Resident #3's care plan titled, Bathing revealed ADL-I prefer whirlpool (T, Th, Sat) on 7-3. Resident will…
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 · D2023-05-25 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident and staff interview, record review and facility policy review, the facility failed to properly administer Percutaneous Enteral Gastrostomy (PEG) flushes during medication administration to a resident, failed to assess the pulse rate before administration of a medication, and failed to have resident rinse the mouth after the administration of an inhaler for two (2) of eight (8) resident medication administrations reviewed. Resident #30 and Resident #77 Findings Include Review of the facility policy titled, Administering Medications, revised April 2019, revealed, Policy heading Medications are administered in a safe and timely manner, and as prescribed .Policy Interpretation and Implementation .2. The director of nursing services supervises and directs all personnel who administer medications and /or have related functions .11. The following information is checked /verified for each resident prior to administering medications: b. Vital signs, if necessary . Review of the facility policy titled, Administering Medication through an Enteral Tube 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 · Dcited before2023-05-25 · 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
Based on observation, staff and resident interview, record review and facility policy review, the facility failed to provide nail care, shaving and appropriate bathing to a resident requiring assistance with Activities of Daily Living (ADL's) for one (1) of 86 residents reviewed. Resident #3 Findings Include Review of the facility policy titled, Activities of Daily Living (ADL), Supporting, revised March 2018, revealed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and oral hygiene. The policy interpretation and implementation revealed under #2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-25 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, record review, and policy review the facility failed to meet a resident's nutritional needs as evidenced by not administering feeding formula at the rate ordered to meet the residents EEN (Exclusive Enteral Needs) for one (1) of seven (7) Percutaneous Endoscopic Gastrostomy (PEG) tube fed residents reviewed. Resident #238 Findings include: Review of the facility policy titled, Enteral Nutrition revised January 2023, revealed Policy Statement Adequate nutritional support through enteral nutrition is provided to residents as ordered. Policy Interpretation and Implementation . 4. Enteral nutrition is ordered by the provider based on the recommendations of the dietitian . An observation of Resident #238 on 5/22/23 at 11:10 AM, revealed Jevity 1.5 formula running at 40 cc/hr. (cubic centimeters/hour) via PEG tube pump. An observation of Resident #238's tube feeding on 5/23/23 at 10:30 AM, revealed Jevity 1.5 running at 40 cc/hr. Directions on the Jevity formula bottle read rate: 50 cc/hr. An observation and interview of Resident #238's tube feeding…
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 · D2023-05-25 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff, and resident interviews the facility failed to prevent the possibility of a foodborne illness as evidenced by out-of-date turkey sandwiches left on a residents overbed table for one (1) of 86 residents reviewed during survey. Resident #60 Findings Include: Record review of the typed statement on facility letterhead revealed the facility did not have a policy regarding food storage in the resident's rooms and was signed by the Administrator. An observation and interview on 05/22/23 at 10:44 AM, with Resident #60 in the resident's room revealed there were three meat and cheese sandwiches wrapped in plastic wrap on top of the resident's overbed table. This observation revealed that each sandwich had a different date, and the dates were 5/15/23, 5/19/23 and 5/21/23. The resident stated, Sometimes I eat them and sometimes I do not. An observation and interview on 5/23/23 at 3:28 PM, with Certified Nurse Assistant (CNA) #2 and CNA #3 confirmed that Resident #60 had three turkey and cheese…
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 before2021-03-25 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, record review and facility policy review the facility failed to provide nail care to for four (4) of six (6) dependent residents. Resident #333, #24, #33 and #10 and failed to ensure a male resident was clean shaven and hair trimmed for (1) of 11 male residents observed for shaving and hair length. Findings Include: Record review of the facility procedure titled, Fingernails/Toenails, Care of, with a revised date of February 2018, revealed, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection .Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. An observation of Resident #24, on 03/22/21, at 11:08 AM, revealed long facial hair and scalp hair. Resident #24's fingernails were long and curved over the end of his fingers. Resident #24 stated that his fingernails needed to be taken care of. He stated that he does not always want to take a bath but does…
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 · D2021-03-25 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, record review and facility policy review the facility failed to provide a call light within reach for one (1) of six (6) total care residents observed, Resident #10. Findings include: Record review of the facility's Answering Call Lights policy dated October 2010, revealed, When the resident is in bed or confined to a chair be sure the call light is within easy reach of resident. On 03/22/21, at 10:45 AM, the State Agency (SA) observed Resident #10's call light tied to resident's right-side rail out of her reach. The SA observed that the resident's right arm was drawn inward to her chest. On 03/22/21, at 10:45 AM, an interview with Resident #10 confirmed that she could not reach her call light and she attempted to reach the call light and was only able to lift her left arm and hand a few inches up and was unable to move her right hand. During the interview, the resident confirmed that she is totally dependent on the staff for her care. On 03/23/21, at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-03-25 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, record review and facility policy review the facility failed to provide phone access in a private location for one (1) of seven (7) residents interviewed, Resident #36. Findings include: Review of facility's Telephones, Resident Use Of policy, dated May 2017, revealed residents shall have easy access to telephones. Designated telephones are available to residents to make and receive private telephone calls. The telephones at the nursing stations should ordinarily be reserved for staff use unless no other alternative is available. Residents should use telephones at the nursing stations for as brief a period as possible. Telephones will be in areas that offer privacy and accommodate the hearing impaired, and wheelchair bound residents. Resident telephones are located in the following areas: Garden Room, East Nurses Station, [NAME] Nurses Station. Review of facility policy titled, Resident Rights dated December 2016, revealed Employees shall treat 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.
- Potential for harm · Dcited before2021-03-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, facility policy review and record review, the facility failed to apply pressure relieving device to residents' feet as ordered for one (1) of four (4) residents reviewed for pressure ulcers. Resident #33. Findings include: Review of the facility policy titled, Memorandum Skin on Skin and Heel Pressure Redistribution, dated 2013, revealed residents who are at risk for developing pressure ulcers have an increased risk of developing pressure ulcers if positioning and pressure redistribution are not taken into account specifically in the areas of skin on skin and the heels. Residents who have contractures or lack of mobility and will be in undesirable positions that could cause increased pressure over bony prominence's need to treat through the use of positioning devices. An observation, on 3/22/21 at 9:18 AM, revealed Resident #33 in bed with no foot protection in place. An observation, on 03/22/21 at 11:50 AM, revealed Resident #33 lying in bed with his feet uncovered. Resident #33 had no foot protection in place. An observation, on 3/23/21 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-03-25 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, record review and facility policy review, the facility failed to apply splints as ordered for one (1) of five (5) residents observed with splints. Resident #48. Findings include: Review of the facility policy, titled, Assistive Devices and Equipment, revised January 2020, revealed the facility maintains and supervises the use of assistive devices and equipment for residents. An observation, on 03/22/21 at 11:22 AM, revealed Resident #48 in her chair. A contracture was noted to her right hand. Resident #48's splints were laying on the bed. Resident #48 stated that they do not put them on. An observation, on 03/22/21 at 3:00 PM, revealed Resident #48's splints remain on the bed in the same place. Resident #48 confirmed the staff had not put her splints on today. An observation, on 03/23/21 at 09:39 AM, revealed Resident #48 up in her recliner chair eating breakfast. Arm splints laying on bed. She stated that she sleeps in her chair. Resident #48 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,788 in federal fines across 1 penalty.
- $8,788 — penalty dated 2025-12-09
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to NEXION HEALTH — 51 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.2 | -1.2 vs chain |
| Health inspection | 1 of 5 | 2.3 | -1.3 vs chain |
| Staffing | 3 of 5 | 2.8 | +0.2 vs chain |
| Quality measures | 2 of 5 | 2.6 | -0.6 vs chain |
The other 50 homes this chain runs (chain average 2.2★, per CMS)
Showing 40 of 50; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NEXION HEALTH OF OHI INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 03/29/2018 |
| NEXION HEALTH LEASING, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/29/2018 |
| NEXION HEALTH, INC. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/29/2018 |
| BOLT, BRETTON | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/29/2018 |
| KIRLEY, FRANCIS | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 03/29/2018 |
| JACKSON, ZAKIYO | Individual | W-2 MANAGING EMPLOYEE | — | since 07/29/2019 |
| LEE, BRIAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/29/2018 |
| OSWALD, JOHN | Individual | CORPORATE DIRECTOR | — | since 03/24/2022 |
| RINER, MEERA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 03/29/2018 |
| PIERCE, DANIEL | Individual | CORPORATE OFFICER | — | since 03/16/2021 |
CMS files one row per role, so the 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 90% 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 $604K 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 255154. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-24, 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.