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Manhattan Community Care Center

4540 Manhattan Rd, Jackson, MS 39206 · For profit - Limited Liability company · 180 certified beds · (601) 982-7421 Medicare & Medicaid certified

Call the home — (601) 982-7421 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Dec 2025Resident-funds citation (F0567)2 actual-harm citations1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$17,901 in federal fines
Insights

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

Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0567)
  • it has 2 actual-harm citations
  • 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 (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $17,901 in federal fines (most recent 2025-09-18)
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (56%) runs well above the national median (45%)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Urgent care / clinic
4500 Interstate 55 North Frontage Rd Ste 128 · (601) 374-7411 · Call to confirm hours
Pharmacy
1220 E Northside Dr Ste 340 · (601) 366-9431 · Call to confirm hours
Grocery
4500 I 55 N · (601) 608-0405 · Call to confirm hours
Park
1505 Eastover Dr · (601) 432-2175 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased28.4%20.5%15.4%worse
Long-stay residents who lose too much weight2.1%6.2%5.4%better
Long-stay residents with a catheter left in their bladder0.5%1.4%0.9%better
Long-stay residents with a urinary tract infection0.2%2.5%2.0%better
Long-stay residents with depressive symptoms0.2%1.6%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury1.7%3.1%3.3%better
Long-stay residents whose ability to walk worsened33.9%19.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication17.0%23.8%18.9%better
Long-stay residents given the seasonal flu vaccine89.5%97.0%95.3%typical
Long-stay residents with pressure ulcers6.8%6.3%4.7%worse
Long-stay residents with worsening bladder/bowel control20.7%20.7%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table21.4%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication4.1%2.5%1.4%worse
Short-stay residents given the seasonal flu vaccine81.9%84.6%79.4%typical
Short-stay residents rehospitalized after admission23.9%27.7%22.6%typical
Short-stay residents with an outpatient ER visit5.3%15.5%12.0%better
Long-stay hospitalizations per 1,000 resident days2.602.431.67worse
Long-stay outpatient ER visits per 1,000 resident days1.342.861.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

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

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

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

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

31.9% 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 79 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

31.9%U.S. median 51.5%
Got home and stayed home
12.0%U.S. median 10.7%
Went back to hospital
0.16U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF31.9%CMS range 23.2–42.051.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.0%CMS range 9.6–17.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 identified90.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting92.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay4.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.1%CMS range 5.7–14.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.211.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.13
RN hours/ resident / day
1.42
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.78
Total nurse hours/ resident / day
0.07
RN hoursweekends
56.4%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 157.2 residents a day — about 87% occupied, or roughly 23 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.78 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.13 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.33 hrs/resident/day on weekends vs 3.96 on weekdays — 16% thinner on weekends. RN hours go from 0.16 to 0.07 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

8
deficiencies at the latest standard inspection (2024-07-25)
6
at the previous standard inspection (2022-09-22)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

32 citations, most serious first. The 13 most serious are shown; the remaining 19 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-09-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and facility policy review, the facility failed to provide adequate supervision and a secure environment to prevent the elopement of one (1) of six (6) sampled residents, Resident #9.On 9/08/25 a newly admitted respite resident with diagnoses of restlessness and agitation, dementia and senile degeneration of brain and history of exit seeking behaviors and falls was assisted to exit the facility by staff, was outside unsupervised for twenty-five (25) minutes until a staff member observed the resident lying on the ground next to the iron fence that encircled the facility premises, approximately three hundred seventy-five (375) feet from the facility entrance.The facility's failure to provide adequate supervision to prevent the elopement of Resident #9 placed this resident, and other residents at risk for wandering and elopement, in a situation that was likely to cause serious injury, harm, impairment, or death. While Resident was out of the facility unsupervised in…

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

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2025-02-27 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, record review, and facility policy review, the facility failed to implement a care plan intervention regarding one-on-one supervision for a severely cognitive impaired resident which resulted in an unsupervised fall, leading to an acute transverse fracture of the lower sacrum for one (1) of two (2) care plans reviewed for falls. Resident #1 Findings Include: A review of the facility's policy, Resident [NAME] of Rights, revised January 2023, revealed: Each resident has a right to a dignified existence, self-determination, and communication with 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 . A. Facility residents shall have the right to: 1 .7 .d. The right to receive the services and/or items included in the plan of care . A record review of Resident # 1's Comprehensive Care Plan, dated 1/27/25, revealed . one-on-one observation when family was not present . A record review of the facility's Supervisor Investigation Summary Form,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-02-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, record review, and facility policy review, the facility failed to provide adequate supervision to prevent accidents and failed to ensure continuous one-on-one supervision resulting in a fall that caused an acute transverse fracture of the lower sacrum, leading to hospitalization for one (1) of two (2) residents reviewed for falls. Resident #1. Findings Include: A review of the facility's policy, Resident [NAME] of Rights, revised January 2023, revealed: Each resident has a right to a dignified existence, self-determination, and communication with 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 . A. Facility residents shall have the right to: 1 .34. A safe environment. A record review of the facility ' s Supervisor Investigation Summary Form, dated 1/31/25, revealed, Briefly describe event: On 1/30/25 around 3:30 PM, (Proper Name of Resident #1) was found sitting in the day room, with his clothes on, in front of his wheelchair. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-05-12 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility policy review, record review and interviews, the facility failed to provide adequate bed linens to maintain a comfortable, homelike environment for one (1) of three (3) floors. Second Floor.Findings Included:Record review of the facility policy titled, Departmental (Environmental Services) - Laundry and Linen Revised January 2014, revealed, The purpose of this procedure is to provide a process for the safe and aseptic handling, washing and storage of linen .On 5/12/26 at 3:30 PM, observation and interview revealed the Resident Representative (RR) for Resident #4 was assisting Resident #4 by changing the linens on her bed and there were no pillowcases available on the second floor. Interview with the RR revealed that she had experienced lack of clean linens available for the care of Resident #4 several times in the past. On 5/12/26 at 3:55 PM, observation revealed Resident #2 had no top sheet on his bed. He was laying on a fitted sheet under a bedspread.On 5/12/26 at 3:58 PM,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably 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 observations, interviews, record reviews and facility policy review the facility failed to ensure call lights were within reach for one (1) of six (6) residents sampled. Resident #2.Findings Included:Record review of the facility policy titled, CALL LIGHT/CALL PAGER SYSTEMS with Revision Date 9/09/22, revealed, Purpose To provide a means of communication to staff for notification of resident needs and a system of communication among staff in the facility; including emergency notifications.All staff.The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room.On 5/11/26 at 12:40 PM, observation revealed the call light for Resident #2 was placed under his bed and came up and over the headboard of his bed, so that the call button was behind the headboard and out of the resident's reach.On 5/11/26 at 2:00 PM, interview with Certified Nursing Assistant (CNA) #2 revealed that each resident was to have their call light in reach to summon…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-12 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews the facility failed to implement the comprehensive, person-centered care plan for one (1) of six (6) sampled residents. Resident #1. Findings Included:Record review of the Care Plan Detail report for Resident #1 revealed Problem: I have stage 4 pressure ulcer to sacrum.Approaches.that included cleanse sacrum with normal saline pat dry apply Santyl cover with dry dressing daily.An additional care plan revealed Problem: I have a stage 4 pressure ulcer to left lower leg.Approaches. cleanse left lateral leg with normal saline pat dry apply Santyl cover with calcium alginate secure with dry dressing daily. On 5/11/20/26 at 2:00 PM, during an observation of Resident #1 and interview with Licensed Practical Nurse (LPN) #1 and Nurse Practitioner (NP) #1 revealed Resident #1 had wound dressings on his sacrum, left lateral calf and left ankle dated 5/09/26. LPN #1 confirmed she had provided wound care for Resident #1 and that the dressings were those she had applied on 5/09/26. LPN #1 confirmed that the resident's care plan specified 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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, record review, facility policy review and interviews the facility failed to ensure ordered wound treatments were administered as prescribed by the physician for one (1) of six (6) residents reviewed for existing skin impairments. Resident #1.Findings Included:Record review of the facility policy titled, Wound Care dated 1/09/22 revealed the policy stated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.After completing a thorough evaluation, the interdisciplinary team should develop a relevant care plan that includes measurable goals for prevention and management of PU/PIs with appropriate interventions.Orders should include.Frequency of dressing change.Document dressing change in medical record .During an interview and observation on 5/11/20/26 at 2:00 PM, an observation with Licensed Practical Nurse (LPN) #1 and Nurse Practitioner (NP) #1 revealed Resident #1 had wound dressings on his sacrum, left lateral calf and left ankle dated 5/09/26. LPN #1 confirmed she had provided wound care for Resident #1 and 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-30 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to implement its abuse prevention policy to protect residents from potential abuse, ensure proper reporting procedures were followed, and prohibit continued staff contact with residents following credible allegations. Specifically, the facility failed to (1) remove the Certified Nursing Assistant (CNA) from all resident care following multiple potential abuse allegations, (2) conduct a timely and complete investigation into resident and family reports of abuse, and (3) implement interventions to protect residents from further potential abuse. This deficient practice affected two (2) of four (4) residents reviewed for abuse (Residents #1 and #2).Findings include:A review of the facility's Abuse Components Plan Elder Just Act and Affordable Care Act, dated 10/24/22, revealed, .The purpose of this policy is to facilitate appropriate. investigation.of actual and/or suspected incidents of abuse.Investigation: Any report of suspected and/or actual resident mistreatment.abuse.will be promptly and thoroughly investigated by facility…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review the facility failed to provide needed care and services that would meet the resident's physical needs as evidenced by wound care not provided in one (1) of two (2) sampled residents with wounds. Resident #4. Findings include:Record review of the facility policy titled Wound Care Treatment Protocol (no review date) revealed the policy instructed staff to: Evaluate the wound daily for signs and symptoms of infection and for signs of healing. Document/Report Findings. Provide treatment as per physician's order.On 09/17/2025 at 9:22 AM, during an interview Resident #4 stated My wound care should be done every 3 days. It was done on 09/11/25 but not on 09/14/25. They just wipe it with wet gauze and cover it up. It's supposed to be irrigated with Dial soap. There's a doctor who sees wounds, but he's never looked at mine.Record review of Resident #4's electronic Treatment Administration Record (eTAR) for September 2025 revealed a physician order for treatment 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-08 · tag F0561 — failed to honor residents' choices — isolated
    Honor 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 observation, interview, record review, and policy review, the facility failed to accommodate resident preferences for two (2) of seven (7) residents reviewed. Residents #3 and #4 Findings include: Review of the facility policy titled A.M. Care, dated 10/09, revealed, A.M. Care will be given to residents daily . Procedure: . 11. Provide/assist with shaving (male and female) as needed . Review of the facility policy titled Hydration Cart, dated 2016, revealed, Water or other fluids shall be offered to all residents throughout the day. Fluids are typically offered during meals, snacks. A hydration cart or location may be used to enhance access and encouragement of fluids for residents. Procedure: 1. The Hydration Cart will be offered or refreshed each day at mid morning, mid afternoon, and bedtime . Resident #4 On 11/06/24 at 3:30 PM, an observation and interview with Resident #4 and his Resident Representative (RR)revealed that water was only provided upon request, and then the resident had to wait for delivery. They stated they would rather the resident have water available…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-08 · tag F0800 — isolated
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and policy review, the facility failed to ensure residents received a diet that was according to the resident preferences for one (1) of seven (7) sampled residents. Resident #1 Findings include: Review of the Facility policy titled Resident Interview and Foot Preferences, dated 2016, revealed, Resident food preferences will be recorded and consistently utilized . On 11/07/24 at 2:30 PM, in an interview with Resident #1, she stated that she hated oatmeal and dietary services put oatmeal on her tray multiple times weekly. Resident #1 stated that she had made staff aware of preferences multiple times. On 11/08/24 at 2:52 PM, an interview with the facility Dietician, she stated that she had stressed the importance of resident food preference to dietary staff and cooks. The Dietician stated she had been made aware that Resident #1 had complained that she did not like oatmeal, and that she had continued to receive oatmeal on her breakfast trays. On 11/08/24 at 5:10 PM, during an interview, the acting Administrator confirmed that whenever possible, he…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure 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

    Based on observation, staff interviews, and facility policy review, the facility failed to maintain sanitary practices within professional standards for food service safety related to hand hygiene for one (1) of two (2) kitchen observations. Findings Included: A review of the facility's policy, Proper Hand Washing and Glove Use, dated 2016, revealed, Guideline: All employees will use proper hand washing procedures .Procedure .4. Employees will wash hands before and after .touching any part of their uniform, face, or hair . On 07/22/24 at 10:29 AM, an observation of the Registered Dietitian (RD) revealed on two (2) occasions while she stood adjacent to the steam table, she picked up an ink pen from the kitchen floor and placed it back on the steam table. After placing the ink pen on the steam table, the RD proceeded to handle a food service utensil which was placed in a pan of pureed pork chops on the steam table, the food thermometer, and the menu book. The RD was observed licking her fingers and flipping through the resident's meal cards that were placed on each tray. On 07/22/24…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-25 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 a safe environment for residents as evidenced by unlocked biohazard rooms on two (2) of four (4) days of survey. Findings Included: During an observation on 07/22/24 at 12:00 PM, there was an unlocked door marked Biohazard on the second floor of the facility. Inside, a red biohazard can was open with red biohazard bags visible, alongside housekeeping chemical dispensers containing Vindicator (a type of disinfectant) and Super Shine All (a type of floor cleaner). A record review of the Safety Data Sheet (SDS), dated 02/04/21, revealed Vindicator had a health hazard for acute oral toxicity and skin corrosion/irritation. A record review of the Safety Data Sheet, dated 10/22/21, revealed Super Shine had a health hazard for serious eye damage/eye irritation. On 7/23/24 at 10:30 AM, during an observation and interview with the Housekeeping and Laundry Supervisor, she observed the biohazard room door was not secured on the second floor of the facility. She stated that biohazard doors should always remain…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · Dcited before2024-07-25 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and facility policy reviews, the facility failed to develop/implement the comprehensive care plan for six (6) of thirty (30) sampled residents. Residents #53, Resident #57, Resident #68, Resident #80, Resident #121, and Resident #122 Findings Included: A review of the facility's policy titled, Care Plan Policy, dated 01/15, revealed POLICY: Each resident would have a plan of care to identify problems, needs, and strengths that will identify how the team will provide care The care plan contained services provided, preferences, abilities, and care level guidelines. Procedure: 1. The Care Plan will be developed within two days. Subsequent meetings would take place yearly and as needed. 2. The team along with the resident and/or family members, will identify services needed, preferences, ability, and care level guidelines. 3. The Care plan will be reviewed and/or revised yearly with the completion of the Admission/Readmission/Yearly Evaluation and with changes in the resident's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-25 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record reviews, and facility policy review, the facility failed to follow professional standards by allowing a Certified Nursing Assistant (CNA) to apply a medicated cream for one (1) of three (3) residents observed for incontinent care. Resident #80 Findings Include: A review of the facility's policy titled, Medication Administration General Guidelines, dated 8/16/24, revealed, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Procedure: 1. Medications are prepared, administered, and recorded only by licensed nursing, medical, or other personnel authorized by state laws and regulations to administer medications. 2. Medications are administered in accordance with written orders of attending physicians taking into consideration manufacturer's specifications and professional standards of practice . An observation on 07/22/24 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-25 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, and facility policy, the facility failed to provide activities of interest to meet the needs for three (3) of 30 sampled residents. Residents #57, #121, and #122 Findings Included: Record review of the facility's policy titled, Activities/Recreation Services Program Planning Consideration reviewed 10/09 revealed, Policy: Interdepartmental communications and available resources will be utilized to plan, design, and implement the activities program for enhancement of resident participation. Responsibility: Activity/Recreational Director or designees Procedure: 1. Planned programming will be coordinated with and communicated to all departments. 2. Adequate and appropriate supplies and equipment will be provided for the resident's use on an individual and group basis. 3. An inventory of equipment and supplies to provide programming will be maintained according to the residents' needs and interests. 4. Supplies will be accessible for residents to use, and signs posted indicating their availability and location. 5. Community resources 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and record review, the facility failed to prevent possible complications related to a resident with an indwelling suprapubic catheter, as evidenced by an observation of the catheter tubing on the floor for one (1) of 1 resident reviewed with a catheter. Resident #117 Findings Included: On 07/22/24 at 11:49 AM, during an observation, Resident #117 was in the dining room in his wheelchair. There was a catheter tubing dragging on the floor as he propelled himself throughout the dining room and hallway. A record review of the Physician Orders for the month of July 2024, revealed an order, dated 4/3/24, for a 16F ( French)10cc (cubic centimeter) suprapubic Foley (type of indwelling catheter) to gravity with a closed urinary drainage bag system . On 07/23/24 at 12:42 PM, during an interview and observation with Licensed Practical Nurse (LPN) #6, she confirmed Resident #117's catheter tubing was in contact with the floor and acknowledged it was an infection control issue. On 07/24/24 at 11:49 AM, during an interview with the Director of Nursing (DON),…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-25 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record reviews, and facility policy reviews, the facility failed to provide a palatable meal for lunch for one (1) of two (2) meal observations. Resident #14 Findings Included: A review of the facility's policy Menu Planning and Requirements, dated 2016, revealed, Guideline: Menus are planned to provide nourishing, palatable, attractive meals that meet the nutritional needs of residents served . On 07/22/24 at 12:39 PM, the State Agency (SA) and the Dietary Manager (DM) sampled a lunch tray consisting of a baked pork chop, cabbage, and macaroni and cheese. The DM noted that the macaroni and cheese was bland and lacked a cheese flavor. The SA team concurred with this assessment. On 07/22/24 at 02:24 PM, during an interview, Resident #14 expressed that the food lacked flavor, specifically noting the macaroni and cheese served at lunch was tasteless. She mentioned the food often lacked taste on certain days. On 07/25/24 at 3:14 PM, during an interview, the Assistant Executive Director (AED) emphasized that she expected the Dietary Manager to prepare…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-25 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility policy reviews, the facility failed to ensure adaptive equipment was consistently provided at each meal for one (1) of one (1) resident observed during mealtime requiring adaptive utensils. Resident #53 Findings Include: A review of the facility's policy titled, Adaptive Devices, dated 2016 revealed, Guideline: Adaptive eating devices will be available to all residents who need them to promote independence in dining. Adaptive devices will be available for residents at mealtime according to their individualized plan of care. Procedure: . 4. Resident meal cards will specify the resident's order for adaptive devices. 5. Food and Nutrition Services staff will provide each resident is given the appropriate devices(s) for each meal . On 07/22/2024 at 12:11 PM during an observation and interview with Resident #53 stated he needed a built-up fork because he was unable to use a conventional fork when eating due to his hand disability. He stated the kitchen…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure residents were provided call light access for communication and resident requests as evidenced by, call lights were out of the reach of residents for two (2) of nine (9) sampled residents. Resident #4 and Resident #5. Findings include: Resident #4 On 5/14/24 at 9:00 AM, during a telephone interview with the facility Ombudsman, she revealed that during her visits she had identified concerns related to call light availability, which she said she had reported to the facility Administrator. On 5/14/24 at 9:25 AM, in a telephone interview with a family member of Resident #4, she revealed she continued to have concerns related to the resident's call light not being available and the resident not receiving assistance as required. The family member stated she was concerned that with the resident not having access to her call light could increase the resident's potential for falls or injury. On 5/14/24 at 3:35 PM, during an observation and interview with Resident #4 revealed she was seated in her wheelchair in…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-16 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that the comprehensive care plans were implemented for two (2) of nine (9) sampled residents. Residents #4 and #5 Findings include: Record review of the facility policy titled, CARE PLANS, reviewed 1/15, revealed, Each resident will have a plan of care to identify problems, needs and strengths that will identify how the team will provide care . Resident #5 Record review of the Care Plan for Resident #5 with a problem onset date of 6/10/22 revealed, Problem/Need: Potential for occasional episodes of urinary incontinence .Approaches .Encourage resident to call for assistance with toileting. Keep call light within reach of resident . Record review of the Care Plan with a problem onset date of 6/10/22 revealed, Problem/Need: Potential for falls related to (R) (right) lower leg pain, and a hx (history) of fall . Approaches . Keep call light within reach of resident . On 5/14/24 at 11:31 AM, an observation revealed Resident #5 was sitting in her wheelchair next to her bed. The call…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, and facility policy review the facility failed to ensure a resident admitted with incontinence of bladder received appropriate treatment and services in a manner to prevent a possible urinary tract infection for one (1) of nine (9) sample residents. Resident #4 Findings include: Record review of the facility policy titled, INCONTINENT CARE, reviewed 1/15, revealed, .Procedure . 11. When washing perineal area, wash the entire area moving from front to back .while using a clean area of the washcloth for each stroke. 12. Rinse the perineal area and other skin surfaces washed with warm water and a washcloth from front to back . On 5/15/24 during a continuous observation of Resident #4 from 10:35 AM through 1:30 PM, revealed the resident was seated in her wheelchair in the day room. The resident was not taken to her room for incontinence check/care until 1:30 PM. On 5/15/24 at 1:35 PM, observation revealed Certified Nurse Aide (CNA) #1 brought a mechanical lift into Resident #4's room and at 1:40 PM, CNA #1 and CNA #2 assisted Resident #4…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-09 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility grievance logs, in-service records, staff interviews, and facility policy review, the facility failed to resolve grievances in a manner that would prevent them from reoccurring as evidenced by four (4) out of six (6) months of resident grievance logs of documented residents' grievances related to call lights not being answered and Certified Nurse Aides (CNAs) not making timely rounds to respond to resident needs. Findings include: Review of the facility's policy titled, Complaint/Grievance Missing Property, undated, revealed, All residents have the right to voice concerns or complaints, which affect their lives at this facility . Complaint may be presented to any staff member; the staff member may resolve the issue immediately. If unable to resolve immediately, follow the Complaint Procedure . The Grievance/Complaint/Missing Property Monthly Tracking Log will be completed by Executive Director on a monthly basis. Any trends, problems identified will be addressed and an action plan initiated. Review of the September Grievance Log revealed a grievance on 9/5/23,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-09-22 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 interviews, and facility policy review, the facility failed to appropriately label opened items in the freezer and walk-in refrigerator and properly store perishable items to maintain food quality and prevent contamination, for one (1) of three (3) dietary observations. This has a potential to affect all residents receiving meals prepared by the facility's dietary department. Findings include: The facility's Labeling and Dating Foods Policy (undated) states, All foods stored will be properly labeled according to the following guidelines . Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date . Once a package is opened, it will be re-dated with the date the item will be use by according to current safe food storage guidelines or by the manufacturer's expiration date . The facility's Food storage (Dry, refrigerated, and Frozen) Policy (undated) states, Food…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-09-22 · tag F0925 — failed to control pests — widespread
    Make 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 observations, staff interviews, facility protocol review, and facility document review, the facility failed to keep pests out of the food preparation and service areas. Roaches were observed in the dietary area on one (1) of three (3) dietary observations. This has a potential to affect all residents receiving meals prepared by the facility's dietary department. Findings Include: Review of the facility's Pest Control Protocol (undated) stated, General Description: Maintain an effective pest control program so that the facility is free of pests and rodents. The Facility maintains an effective pest control program . A record review of facility pest control contracts revealed that the facility has pest control contracts with two (2) pest control vendors that according to invoices are providing monthly services. The contract with Vendor #1 was signed on 1/17/22, with the second pest control contract was signed on 6/3/22. On 09/20/22 at 11:05 AM, the State Agency (SA) observed four (4) roaches in the dietary area. Two (2) roaches were seen on the storage cart that holds plates,…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-22 · tag F0567 — failed to protect residents' money held by the home — isolated
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and facility policy review, the facility failed to ensure that residents have reasonable and ready access to their funds, as funds are not available on weekends. This deficient practice has the potential to affect 95 of 95 residents with funds held by the facility. Findings Include: Review of the facility's Resident [NAME] of Rights, dated 11/17, revealed, Each resident has a right to a dignified existence, self-determination, and communication with 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 .22. Manage his or her financial affairs. The resident must authorize the facility in writing to manage any personal funds and the facility must ensure the resident has reasonable and ready access to those funds . On 09/20/22 at 02:07…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-22 · tag F0576 — isolated
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility policy review and resident and staff interviews, the facility failed to ensure that residents received their mail promptly, within 24 hours of delivery. This had the potential to affect 131 of 131 residents residing at the facility. Findings include: Review of the facility's Resident [NAME] of Rights, dated 11/17, revealed, Each resident has a right to a dignified existence, self-determination, and communication with 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 .27. To send and receive mail promptly and unopened . During an interview on 09/20/22 at 2:00 PM, during a Resident Council meeting, the residents complained that they do not receive their mail on weekends because the Activities Director is off on weekends. There were 17 residents in…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-22 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and facility document review, the facility failed to complete and transmit the Minimum Data Set (MDS) within the required timeframe for three (3) of 31 sampled residents. Resident #1, Resident #11, and Resident #20. Findings Included: A record review of a facility's document presented to the State Agency (SA) by Registered Nurse (RN) #1/Case Mix Consultant, undated, revealed, (Proper Name of Facility) uses the Resident Assessment Instrument (RAI) Manual to code all assessments. A record review of Center for Medicare and Medicaid Services (CMS)'s Resident Assessment Instrument (RAI) Version 3.0 Manual revealed . 5.2 Timeliness Criteria . For all non-admission OBRA (Omnibus Budget Reconciliation Act) and PPS (Prospective Payment System) assessments, the MDS Completion Date . must be no later than 14 days after the Assessment Reference Date (ARD) .For the admission assessment, the MDS Completion Date .must be no more than 13 days after the Entry Date .The Submission Time Frame…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-22 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, facility documentation, and clinical record review, the facility failed to ensure one (1) out of four (4) residents reviewed for Pre-admission Screening and Resident Review (PASARR) were referred for a Level II PASARR after development of a serious mental disorder. Resident #62. Findings Include: Record review of the Pre-admission Screening (PAS) dated 2/12/21 for Resident #62 revealed the resident did not have a serious mental disorder upon admission. Record review of Resident #62's Face Sheet revealed an admission date of 2/11/21. Record review of services provided to Resident #62 on 2/24/22 by Behavioral Health Services LLC, revealed a new diagnosis of Bipolar Disorder. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/18/22, revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Review of Section I included diagnosis of Bipolar Disorder and Section N revealed #62 had received Antipsychotic medication six (6) of the last seven (7) days. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-05-23 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, record review, and facility policy review, the facility failed to follow Resident #173's comprehensive care plan related to catheter care for one (1) of three (3) care plans reviewed for catheter care. Findings include: A review of the facility's Comprehensive Person Centered Care Plans policy, with a latest revision date of 03/18, revealed each resident will have a person centered plan of care to identify how the interdisciplinary team will provide care. Assigned disciplines will be identified to carry out the intervention. A review of the comprehensive care plan, with an onset date of 02/9/16, revealed the Problem/Need for the potential for Urinary Tract Infection (UTI) related to the presence of an indwelling Foley catheter and history of urinary retention. The Goal & Target Date stated the resident would not have any signs and symptoms of a UTI thru 07/20/19. On 05/21/19 at 10:10 AM, an observation revealed Resident #173 was lying in bed with an indwelling urinary catheter to gravity drainage. Further observation revealed Certified Nursing Assistant…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-05-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, record review, and facility policy review, the facility failed to provide catheter care in a manner to prevent possible cross contamination/Urinary Tract Infection (UTI), for one (1) of three (3) residents reviewed with catheters. Resident #173. Findings include: On 5/21/19 at 10:10 AM, an observation revealed Certified Nursing Assistant (CNA), assisted by CNA #2, provided Resident #173's catheter care#173 was lying in bed with an indwelling urinary catheter to gravity drainage. Both CNAs washed their hands and applied clean gloves. CNA #1 wiped the resident's perineal area in a downward motion on each side of the resident's groin areas, and down the middle of the resident's vaginal area. While CNA #1 held the catheter tubing at the distal end farthest away from the meatus, she wiped the catheter tubing towards the meatus two times, and after CNA #2 told her not that way, CNA #1 then wiped the catheter tubing away from the meatus area twice. CNA #1 held the catheter tubing with her left hand at the distal end from the meatus, while using her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-05-23 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, record review and facility policy review, the facility failed to prevent the possible spread of infection during med pass for one (1) of six (6) residents observed during the medication pass, Resident #135. Findings include: Review of the facility's Contact Precautions policy, revised 10/2009, revealed the staff were to wash their hands after contact with the resident and before leaving the room. The policy also stated to dispose of contaminated items in a proper receptacle after care is completed by placing in a plastic bag, closed prior to leaving the room. An observation and interview, on 05/21/19 at 11:27 AM, with Licensed Practical Nurse (LPN) #1 confirmed Resident #135 was on Contact Precautions. There was signage for Contact Isolation on the resident's room door. LPN #1 entered the room to perform a finger stick glucose test on Resident #135. LPN #1 placed the supplies on a disposable plate, and then placed plate on the overbed table without wiping the table off with a sanitizing wipe or placing the place on a surface barrier. LPN #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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$17,901 in federal fines across 3 penalties.

  • $9,113 — penalty dated 2025-09-18
  • $4,394 — penalty dated 2025-02-27
  • $4,394 — penalty dated 2025-02-27

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 / managerTypeRoleSince
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.

$16.5M
Net patient revenuemost recent cost report
-4.2%
Operating marginrevenue minus expenses
$2.7M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 81%Medicare 8%Other / private 11%

About 81% 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 $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 16% 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

$318per resident / day
operating cost
$9,678per month
≈ monthly operating cost
$306per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MS

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Mississippi Medicaid page.

Typical monthly cost in Mississippi
$9,581/mo
Nursing home (semi-private)
$9,885/mo
Nursing home (private)
$4,369/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 255115. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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