Chadwick Community Care Center
1900 Chadwick Drive, Jackson, MS 39204 · For profit - Corporation · 102 certified beds · (601) 372-0231 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,281 in federal fines (most recent 2025-05-14)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (72%) runs well above the national median (45%)
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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 1 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 | 1 of 5 |
| Long-stay residentspeople who live here | 3 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 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 | 23.9% | 20.5% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.1% | 6.2% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.2% | 1.4% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.3% | 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 | 0.6% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 12.4% | 19.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 17.3% | 23.8% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.2% | 6.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 29.6% | 20.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.1% | 21.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 91.9% | 84.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 36.7% | 27.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 20.8% | 15.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.08 | 2.43 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.89 | 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.
31.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 58 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 40.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 35 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: 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 22% 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 | 31.4%CMS range 22.6–45.0 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 7.0–14.7 | 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 | 40.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 42.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 37.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were 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 | 64.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 | 4.5% | 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 | 7.7%CMS range 4.6–15.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.33 | 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 102 beds and averages 89.1 residents a day — about 87% occupied, or roughly 13 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.17 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 3.36 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.46 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 72% is well above 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.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Immediate jeopardy · J2025-05-14 · 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, interviews, record review, facility policy review, and facility investigation review, the facility failed to provide adequate supervision of Resident #1, who was identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. On 5/09/25, at approximately 7:45 AM, Resident #1 exited the facility while unsupervised wearing a wander alarm device. The resident was out of the facility unsupervised and walked approximately one (1) mile crossing a four-lane highway for approximately two (2) hours before being located and returned to the facility. The facility's failure to provide adequate supervision for Resident #1, who was an elopement risk, put this resident and all other residents at risk for wandering and elopement, at risk for serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 5/09/25, when…
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 · D2026-07-02 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review and interviews, the facility failed to consult with the primary care provider regarding the psychosocial status of the resident which resulted in missed dialysis treatments for one (1) of three (3) residents dependent on dialysis treatments. Resident #1. Findings Included:Record review of the facility policy, Change in a Resident's Condition or Status revised February 2021 revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been .significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly; refusal of treatment or medications two (2) or more consecutive times) . On [DATE] at 1:32 PM during a telephone interview, the Resident Representative (RR) for Resident #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 · Dcited before2026-07-02 · 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 record review, facility policy review, and interview the facility failed to develop a person-centered comprehensive care plan to meet and address the resident's psychosocial needs for one (1) of four (4) sampled residents. Resident #1.Findings Included:Record review of the facility policy, Interdisciplinary Comprehensive Care Planning with effective date 6/02/16 revealed, The comprehensive care plan is an interdisciplinary communication tool It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The interdisciplinary team in conjunction with the resident and his/her family and/or responsible party as appropriate will develop, evaluate and amend as needed.Record review of the care plans for Resident #1 revealed there was not a care plan in place that addressed resident behaviors or psychosocial needs.On 6/30/26 at 12:50 PM, during an interview with Resident #1, he revealed that he required assistance and confirmed that…
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 · D2026-07-02 · tag F0742 — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
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 facility policy review, record review and interviews, the facility failed to provide the appropriate treatment and services to address known psychosocial concerns in order to attain the highest practicable mental and psychosocial well-being for one (1) of four (4) sampled residents. Resident #1. Findings Included:Record review of the facility policy, Behavioral Health Services with Revised Date February 2019 revealed, The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care .Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care.During a telephone interview, on [DATE] at 1:32 PM, the Resident Representative (RR) for Resident #1 revealed that she was concerned related to the resident missing medical and dialysis appointments.…
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 before2026-01-29 · 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
Based on observations, interviews, record review and facility policy review, the facility failed to consistently provide necessary activities of daily living (ADL) care, including daily oral hygiene, routine nail care, and regular shaving of facial hair for one (1) of (19) residents reviewed. Resident #78.Findings include: Record review of the facility policy, Activities of Daily Living (ADL's) Supporting revised March 2018, revealed, .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.On 1/27/26 at 11:51 AM, during an interview with Certified Nursing Assistant (CNA) #1, he stated that he had been assigned to provide ADL care to Resident #78 for the past two days. He explained that oral care and grooming, such as shaving, are routine parts of ADL care. He acknowledged that he had failed to perform this type of ADL care for Resident #78 but stated he could do it now if the State Agency (SA) would like him to.On 1/27/2026 at 11:54 AM, 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 · Dcited before2026-01-29 · 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, interviews, record reviews and facility policy review the facility failed to implement a comprehensive care plan related to Activities of Daily Living (ADL) and wound care for two (2) of six (6) care observations. Resident #60 and Resident #78. Findings Include: Record review of the facility policy Comprehensive Person Centered, revised 03/2022, revealed, A comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident's physical, psychosocial, and functional needs is developed and implemented for each resident . Resident #60 Record review of Resident #60's Care Plan Report with a date initiated of 12/29/2025 revealed .Approaches/Tasks: Cleanse site with wound cleanser, pat dry, apply skin preparation and barrier cream, and cover with a dry dressing daily and as needed . On 01/28/2026 at 1:39 PM, an observation of wound care was conducted by Licensed Practical Nurse (LPN) #4. LPN#4 cleansed the wound with wound cleanser but did not pat dry prior to betadine application as ordered by the physician orders and 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 · D2026-01-29 · 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, interview, record review, and facility policy review, the facility failed to follow standards of practice during medication administration and wound care for two (2) of five (5) residents observed for medication administration and wound care. Residents #8 and #60.Findings Include: Record review of the facility policy Wound Care, revised 1/9/22, revealed The purpose of the procedure is to provide guidelines for the care of wounds to promote healing . Record review of the facility policy Administering Medications through an Enteral Tube, undated, revealed, General Guidelines. Administer each medication separately and flush between medications . Resident #8 On 01/28/2026 at 8:30 AM, Licensed Practical Nurse (LPN) #1 was observed administering medications to Resident #8 via percutaneous endoscopic gastrostomy tube. During medication administration, the nurse administered multiple medications through the tube without flushing with water between each medication. The tube became clogged, requiring the nurse to use a syringe plunger to push the medications 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 · Dcited before2026-01-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to ensure an indwelling urinary catheter was secured with a leg strap for one (1) of four (4) residents reviewed with urinary catheters. Resident #2.Findings Include:Record review of the facility policy Catheter Care, Urinary, undated, revealed .Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site .On 01/29/2026 at 10:53 AM, during an observation and interview of foley catheter care conducted by Certified Nursing Assistant (CNA) #3, assisted by CNA #4 revealed upon removal of Resident #2's pajamas a leg strap to secure the catheter was not in place. CNA #3 and CNA #4 confirmed there was not a leg strap in place to secure the catheter. CNA #4 stated Resident #2 should have a leg strap. She stated the purpose is to prevent the catheter from pulling out. She stated she notifies the nurse when one is not present.On 01/29/2026 at 2:56 PM, during an interview, the Director of Nursing (DON) stated CNAs should apply a leg strap during…
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 · D2026-01-29 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were clinically indicated and free from unnecessary use for one (1) of seven (7) sampled residents reviewed for unnecessary medications. Resident #5.Findings Include:Record review of Resident #5's medication orders revealed an active order for Narcan Nasal Liquid 4 milligrams per 0.1 milliliters, spray alternating nostrils every two minutes as needed for signs and symptoms of overdose including unresponsiveness, shallow breathing, and cyanosis, with instructions to notify the Medical Doctor and Emergency Medical Services immediately. (Narcan is indicated to reverse the effects of opioid overdose.) Record review of Resident #5's medication orders revealed an active order for Narcan Nasal Liquid 4 milligrams per 0.1 milliliters, spray alternating nostrils every two minutes as needed for signs and symptoms of overdose including unresponsiveness, shallow breathing, and cyanosis, with instructions to notify the Medical Doctor and Emergency Medical Services…
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 · D2026-01-29 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 provide alternative menu choices and ensure meal preference options were communicated for one (1) of (19) sampled residents reviewed for food service choices. Resident #70.Findings Include:On 01/27/2026 at 12:32 PM, during an interview, Resident #70 stated he sometimes does not like the food he is served. He stated he did not know alternate meals were available. He stated when he tells the Certified Nursing Assistants (CNAs) he does not like the meal served, sometimes they bring something else and other times they do not. He stated he is not aware of what foods are being served daily and would like to know what is being served.On 01/28/2026 at 11:06 AM, during an interview, Resident #70 stated he still did not know what foods would be served that day. Observation of the resident's room revealed there was not a menu posted in the room.On 01/28/2026 at 11:23 AM, during an interview, the Dietary Manager stated menus are posted on each hall. She stated CNAs ask residents at lunch and notify kitchen staff of…
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 before2026-01-29 · 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 observation, interview, record review, and facility policy review, the facility failed to follow infection prevention and control guidelines during medication administration for one (1) of four (4) residents reviewed for medication administration. Resident #8. Findings Include:Record review of the facility policy, revised October 2018, revealed This facility's infection control policies and practices are intended to. help prevent and manage transmission of disease and infection.On 01/28/2026 at 8:30 AM, medication administration was observed for Resident #8 via percutaneous endoscopic gastrostomy tube. Prior to administration, Licensed Practical Nurse (LPN) #1 removed the stopcock plunger from the feeding tube syringe and placed it on top of the plastic container it came in. During medication administration, the stopcock plunger slid off the plastic container onto the bare bedside table, which had not been disinfected prior to medication preparation. During the medication administration process, the resident's feeding tube became clogged, requiring LPN#1 to use the stopcock…
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 · E2025-09-17 · tag F0628 — patternProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility statement review the facility failed to issue a bed-hold notice when a resident went out on therapeutic leave for one (1) of two (2) residents reviewed for discharge. (Resident #1).Findings Include:Record review of a typed statement on facility letterhead and signed by the Executive Director (ED) revealed, The facility does not have a policy for Bed Hold. On 09/15/25 at 4:42 PM, in an interview the ED stated Resident #1 was discharged due to escalating behavior. She would pull her dress while walking down the hall and go into male residents' rooms. She stated Resident #1 was discharged for her safety and welfare. She stated the facility could not meet her needs. She stated Resident #1's family declined the 30-day notice. Resident#1 left on 5/30/25 and family decided to take resident home. Resident was discharged on 5/30/25 due to the family decision.On 09/16/25 at 10:58 AM, a phone interview with Resident #1's Resident Representative (RR) stated that Resident #1 is with her sister at this time. The RR stated he received only one…
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 before2025-09-17 · 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
Based on observation, interview, record review, and facility policy review, the facility failed to implement the comprehensive care plan while providing perineal care for one (1) of two (2) residents observed for activities of daily living (ADL) care (Resident #4).Findings Include:A record review of the facility's Comprehensive Person-Centered Care Plans dated 1/25 revealed, Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences and goals that will identify how the interdisciplinary team will provide care .A record review of Resident #4's Care Plan Report revealed a care plan with an initiation date of 10/2/24, Focus: (Proper name of Resident #4) is incontinent of bladder and bowel.Interventions. Incontinent checks/care every two (2) hours and as needed (PRN) x (times) 2-person assistance for total dependence . On 9/16/25 at 4:03 PM, during an observation of perineal care revealed CNA #1 provided perineal care without 2-person assistance as indicated on the care plan. On 09/16/25 at 4:16 PM, during an interview CNA #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 · Dcited before2025-09-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record reviews and facility policy review the facility failed to provide perineal (peri-care) according to acceptable standards for one (1) of two (2) observations. Resident #4.Findings Include:A record review of the facility's Incontinent Care dated 07/12 revealed .10. Wash the resident's entire perineal area, and all areas affected by incontinence with a washcloth, soap, warm water, peri-wash or wipes. 11. When washing perineal area, wash the entire perineal, wash the entire area.On 09/16/25 at 4:03 PM, in an observation, Certified Nursing Assistant #1 (CNA) provided perineal care for Resident #4. CNA #1 placed the feeding pump on hold. He used three wipes and wiped front to back in the groin area on the right side. He then folded the wipe and wiped the same area again. He retrieved three (3) more wipes and wiped the left side front to back. He picked up the remaining wipes and wiped down the center of the vagina front to back one time. He turned resident on her left side to remove soiled brief. He placed soiled brief on the bed and placed a clean…
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 before2025-09-17 · 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 observation, interview, record review, and facility policy review, the facility failed to provide perineal care in a manner that would prevent the possible spread of infection for one (1) of two (2) residents observed for perineal care. (Resident #4).Finding include:A record review of the facility's Hand Washing policy, with a history of 9/19 revealed POLICY: Staff will use proper handwashing technique to prevent the spread of infection.A record review of the facility's Enhanced Barrier Precautions (EBP) policy, with a history of 4/24 revealed . 2. Enhanced Barrier Precautions only require use of gown/gloves when performing high contact resident.f. Changing briefs or assisting with toileting .A record review of the Enhanced Barrier Precautions (EBP) signage revealed that everyone must clean their hands, including before entering and when leaving the room. The signage further revealed that providers and staff must wear gloves and gowns for high-contact resident care activities, including changing briefs, assisting with toileting .On 9/16/25 at 4:03 PM, observed signage on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-06-05 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 and record review, the facility failed to have sufficient nursing staff to meet the needs of residents as evidenced by failure to answer call lights and provide incontinent care in a timely manner for three (3) of 19 sampled residents, with the potential to affect all residents residing in the facility. (Residents #48, #87 and #23) Findings Include: Resident # 48 On 06/02/24 at 12:50 PM, an observation and interview of Resident #48, revealed a Certified Nurse Aide (CNA) entered the resident's room and turned off the resident's call light and exited the room. When the resident's room was entered, there was a strong unpleasant odor. Resident #48 stated the CNA turned off her call light and said that she would be back. The resident complained that this is something that happens frequently and it takes a long time for them to return to provide the requested care. The resident was unable to provide information regarding shifts and timing of the occurrences, adding…
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 · D2024-06-05 · tag F0561 — failed to honor residents' choices — isolatedHonor 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 observations, interviews, record review, and facility policy review, the facility failed to honor resident's rights to have a choice of having bedrails for assistance with turning and bed mobility for two (2) of 19 sampled residents. Resident #54 and #78 Findings include: A record review of the facility's policy titled, Resident [NAME] of Rights, dated 01/23 revealed, Each resident has a right to a dignified existence, self-determination, and communication wish and access to persons and services inside and outside the facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life, regardless of diagnosis, severity of condition or payment source and to exercise those rights as a citizen of the United States without interference, coercion including those rights specified herein . Resident #54 On 06/02/24 at 12:38 PM, during an interview with Resident #54, he revealed he wanted rails on his bed, but was told by the facility staff that he could not have rails due to the state's regulations. On 06/05/24 at 9:39 AM, during 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 · Dcited before2024-06-05 · 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
Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure timely incontinent care was provided for one (1) of two (2) residents observed for incontinent care. Resident #48 Findings include: Record review of the facility's policy titled, Resident [NAME] of Rights dated 01/23 revealed, Each resident has a right to a dignified existence . On 06/02/24 at 12:50 PM, an observation and interview revealed Resident #48's call light was on. At that time, a Certified Nurse Aide (CNA) entered the resident's room and turned off the light and exited the room. When the resident's room was entered, there was a strong unpleasant odor noted. Resident #48 reported she had told the CNA she needed to be changed. The resident stated the CNA turned the light off and said she would come back. The resident complained that it takes a long time for staff to answer her light, and when they do, they turn off the light and then it takes forever for them to come back to provide the care that had been requested. The resident then added that this…
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 · D2024-06-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure oxygen was delivered in a manner to prevent potential complications as evidenced by not following physician orders or facility policies related to oxygen therapy when a resident's oxygen tubing was not dated and there was no humidification provided for one (1) of 19 sampled residents. Resident #52 Findings Include: Record review of the facility's policy titled, Oxygen Therapy, reviewed 1/15, revealed, Oxygen is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress . Equipment: . 2. Humidifier, if needed . Procedure: .8. Change tubing weekly. 9. Date tube when changed (weekly). On 6/02/24 at 1:02 PM, an observation and interview with Resident #52 revealed Resident #52 was sitting on her bed with oxygen flowing at 2 liters per nasal cannula. The oxygen tubing did not have a date on it, nor was there a humidifier bottle attached to the delivery system. Resident #52 stated she has been hospitalized two times due to shortness of breath.…
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 before2023-11-13 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility policy review and staff interviews the facility failed to provide safe and secure storage of medications for one (1) of three (3) medications carts observed. Findings Include: Record review of the facility provided Medication Administration-General Guidelines dated 8/16, revealed, . 4. Medications are administered at the time they are prepared for each resident. Medications are not pre-poured .16 . No medications are left unattended on top of the cart. The cart is to be locked if not clearly visible and under the control of the personnel administering medications . On 11/09/23 at 8:20 AM, an observation revealed the medication cart outside room [ROOM NUMBER] was unattended, unlocked, and had three medication packets, containing four pills lying on top of the medication cart. There were no residents in the hallway. The medication packets lying on top of the medication cart were labeled Divalproex Sprinkles mcg (micrograms) 2 CAPSULES, Losartan 50 MG (milligrams) one (1) TABLET,…
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 · E2023-05-18 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 that residents who do not have an Advance Directive (AD) received information or assistance in formulating an AD for ten (10) of ten (10) residents reviewed for ADs. This deficient practice had the potential to affect all residents who do not have an AD. Resident #11, Resident #14, Resident #21, Resident #31, Resident #45, Resident #55, Resident #65, Resident #67, Resident #86, and Resident #90. Findings include: A review of the facility's policy Advance Directives dated 8/2017, revealed, .It is the policy of the Facility to respect the resident's right of self-directed care including the right to issue Advance Directives .2. Upon admission the Facility will provide each resident medically deemed competent or resident's representative, who does not have an existing Advance Directive, with written information and instruction regarding the right to make Advance Directives prior to the initiation of care or at any requested time .c. The resident's instructions, the resident's receipt of…
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 before2023-05-18 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to date an opened insulin vial and failed to a remove an expired insulin pen and insulin vial from medication carts for two (2) of three (3) medication carts reviewed. Findings include: A record review of the facility's policy, Expiration Dating and Document Requirements, with a revision date of 01/2015, revealed, . Medications will be discarded by the product expiration date OR the date on which the suggested length of time after opening the product has passed, whichever occurs first . A record review of the facility's policy, Insulin Pens, with a revision date of 08/2016, revealed, . Check the date the insulin pen was opened and discard per manufacturers' guidelines. Date and initial new insulin pens upon opening . On [DATE] at 4:20 PM, an observation of the A hall medication cart with Licensed Practical Nurse (LPN) #2, revealed a vial of Humulin R 100 unit/ml Insulin in a box without an open date on the box or…
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 · D2023-05-18 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interviews, and facility policy review, the facility failed to ensure a written notification of transfer was sent to the Resident's Responsible Representative, included the reason of transfer for one (1) of two (2) records reviewed. Resident #88. Findings include: A record review of the facility's policy, Discharge and Transfer Policies - Involuntary reviewed 1/15, revealed, Policy: Transfer and discharge includes movement of a resident to a bed outside of the facility whether that bed is in the same physical plant or not . Procedure: . 6. Before a facility transfers a resident to a hospital .the nursing facility must provide written information to the resident and a family member or legal representative that specifies the duration of the bed-hold policy and the facility's policies regarding bed-hold policies . A record Review of Resident #88's Discharge/Transfer Notice, dated 05/11/23, revealed the resident was transferred to an acute care hospital. No reason for hospitalization was evident of the form. A record review of Resident #88's Physician's Telephone…
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 before2023-05-18 · 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 observations, interviews, record review, and facility policy review, the facility failed to implement a care plan to include providing the necessary behavioral health services per physician orders for one (1) of two (2) residents reviewed for behaviors. Resident #90 Findings include: A record review of the facility's policy Comprehensive Person-Centered Care Plans dated 3/18, revealed, . Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care . A record review of Resident #90's Comprehensive Care Plan, revealed a problem onset of 03/31/23, stating the resident .has the potential for alteration in mood as evidenced by verbal aggression . and approaches listed included . Psychological assessment as needed . Record review of Resident #90's Physician's Telephone Orders dated 03/16/23, revealed .may transfer resident to Geri Psych hospital for evaluation . Another Physician's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-18 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to provide the necessary behavioral health services per physician orders for one (1) of two (2) residents reviewed for behaviors. Resident #90 Findings include: On 05/15/23 at 12:10 PM, an observation of Resident #90 revealed he was standing in his doorway talking very loudly to a staff member about the red things in his corn. He kept repeating numerous times, I don't know what they are, so I am not eating it. Resident #90 was observed getting louder as he continued to stand in his doorway talking about his corn to anyone he saw coming down the hall. On 05/15/23 at 12:35 PM, Resident #90 was observed sitting in a chair in his room, continuing to loudly complain about the corn. The resident appeared very anxious while talking about his corn and his recent hospitalization. Resident #90 explained the facility sent me to the hospital because I said I was leaving on the 1st of the month and they wanted to see if I was for real, but I wasn't. On 05/17/23 at 02:15 PM, during an interview with Certified 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.
“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
$8,281 in federal fines across 1 penalty.
- $8,281 — penalty dated 2025-05-14
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 |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — 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 84% 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 $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 255125. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-29, 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.