Ocean Springs Health & Rehabilitation Center
1199 Ocean Springs Road, Ocean Springs, MS 39564 · For profit - Corporation · 115 certified beds · (228) 875-9363 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (4/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $22,410 in federal fines (most recent 2025-02-13)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.8% | 20.5% | 15.4% | typical |
| Long-stay residents who lose too much weight | 6.7% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.3% | 1.4% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.0% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 1.6% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.0% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 13.8% | 19.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.2% | 23.8% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.7% | 6.3% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 28.9% | 20.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.0% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 2.5% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 95.5% | 84.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 21.8% | 27.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 15.0% | 15.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.00 | 2.43 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.82 | 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.
50.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 131 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 79.4% 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 63 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 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% 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 | 50.3%CMS range 41.7–58.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.0%CMS range 9.1–16.9 | 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 | 79.4% | 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 | 60.3% | 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 | 69.8% | 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 | 86.2% | 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 | 81.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 | 4.8% | 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 | 8.0%CMS range 5.0–12.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.12 | 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 115 beds and averages 105.1 residents a day — about 91% occupied, or roughly 10 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 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 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 2.77 hrs/resident/day on weekends vs 3.50 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.68 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
30 citations, most serious first. The 13 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-02-13 · 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 interviews, record review, facility policy review, and facility investigation review, the facility failed to implement care plan interventions for a Resident #1, who was identified as an elopement and wandering risk for one (1) of four (4) residents reviewed. Resident #1 On 2/08/25, at approximately 3:00 PM, Resident #1 exited the facility while unsupervised wearing a wander alarm device that was found to be inoperable. The resident was out of the facility unsupervised and walked approximately 0.7 miles for approximately thirty (30) minutes before being located by facility staff and returned to the facility, crossing a four-lane highway. The facility's failure to implement resident's care plan interventions related to wandering and elopement for Resident #1, 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 Immediate Jeopardy (IJ), which began on 2/08/25, when Resident #1 exited the facility. The State Agency (SA) notified the Administrator…
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.
- Immediate jeopardy · Jcited before2025-02-13 · 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
Based on observation, interviews, record review, facility policy review, and facility investigation review, the facility failed to provide adequate supervision and assessment and monitoring of a wandering alarm device to prevent 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. Resident #1 On 2/08/25, at approximately 3:00 PM, Resident #1 exited the facility while unsupervised wearing a wander alarm device that was found to be inoperable. The resident was out of the facility unsupervised and walked approximately 0.7 miles for approximately thirty (30) minutes before being located by facility staff and returned to the facility, crossing a four-lane highway. The facility's failure to adequately assess and monitor the resident's wandering alarm device and 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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-04-18 · 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 review, and facility policy review, the facility failed to provide incontinence care in a timely manner for six (6) of 22 sampled residents and resulted in Resident #57 having skin excoriations and Resident #55 free from wearing two (2) incontinence briefs with a current diagnosis of Urinary Tract Infection (UTI). (Residents #57, #55, #1, #8, #14, and #38) Findings include: Resident #57 On 4/15/24 at 10:00 AM, during an observation, staff were transferring Resident #57 from the bed to an electric wheelchair using a mechanical lift. On 4/15/24 at 4:00 PM, during an observation and interview, Resident #57 was in his electric wheelchair and stated that he had been up in his chair since 10:00 AM and the staff had not changed his brief since then. He explained that he usually wears two (2) incontinence briefs during the day to hold his urine because it takes several staff members to transfer him with the lift and to change him. On 4/15/24 at 4:15 PM, during an observation of incontinence care for Resident #57, Certified Nurse Assistants (CNAs) #3,…
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 · D2026-06-22 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review, the facility failed to revise Resident #1's comprehensive, person-centered care plan to include individualized interventions for physician-ordered wound care for one (1) of three (3) residents reviewed for care planning, Resident #1.Findings include:A review of the facility's policy Care Plan Revisions Upon Status Change, revised 11/14/2025, revealed, Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change .A record review of the admission Record revealed the facility admitted Resident #1 on 5/20/26 with diagnoses including Amputation. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/26/26 revealed Resident #1 had a Brief…
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 · D2026-06-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 staff interview, record review, and facility policy review, the facility failed to provide treatment and services in accordance with professional standards of practice by failing to timely transcribe physician-ordered wound care into the resident's medical record and failing to document physician-ordered wound treatments in the clinical record for one (1) of three (3) residents reviewed for wound care (Resident #1).Findings include:A review of the facility's policy Documentation of Wound Treatments revised 11/7/2025 revealed, Policy: The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment.Policy Explanation and Compliance Guidelines.3. Wound treatments are documented at the time of each treatment. A review of the facility's policy Provision of Quality of Care, undated, revealed Policy: Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified…
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 · Fcited before2025-09-11 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 interview, and facility policy review, the facility failed to maintain food quality and hygienic practices in accordance with professional standards for food safety related to overly ripened produce, improperly stored food, exposed food, expired food, and unsanitary handling of ready-to-eat food for two (2) of (2) kitchen observations.Findings include:A review of the facility's policy, Sanitation Inspections, Nutrition, and Food Service, with an effective date of 11/30/2014, revealed, .Each item is labeled and dated before refrigeration. Avoid indiscriminate handling of foods with fingers. The proper use of hands, gloves and serving utensils shall be taught to all food handlers .On 09/08/2025 at 10:15 AM, during an observation and interview of the kitchen with the Dietary Manager (DM), Refrigerator #1 was observed to contain two (2) small plates with individual portions of lettuce, tomato, and onions that were not dated, and one (1) cut piece of overly ripe cucumber with dark spots. Refrigerator #2 was observed to contain four (4) bunches of overly ripe…
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 · Fcited before2025-09-11 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to accurately report staffing data to the Centers for Medicare and Medicaid Services (CMS) using payroll and other verifiable sources in a uniform format, for one (1) of four (4) quarters reviewed, FY (Fiscal Year) Quarter 3 2025 (April 1-June 20) resulting in the facility triggering for excessively low weekend staffing, no Registered Nurse (RN) hours, and no licensed nursing coverage 24 hours/day.Findings include:A record review of the Payroll Based Journal (PBJ) Staffing Data Report for the third (3rd) quarter (4/1/25 through 6/30/25) revealed the facility triggered for Excessively Low Weekend Staffing, No RN Hours, and Failed to Have Licensed Nursing Coverage 24 Hours/Day. Further review revealed the Infraction Dates for No RN Hours and Failure to Have Licensed Nursing Coverage 24 Hours/Day were 4/1/25 through 4/30/25 and 5/1/25 through 5/31/25.A record review of the Staffing Grid, completed by Human Resources staff member Licensed Practical Nurse (LPN) #4, revealed the facility had RN and nursing coverage on all days 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.
- Potential for harm · E2025-09-11 · tag F0867 — failed to act on quality-improvement findings — patternSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent the recurrence of previously cited deficiencies, specifically, the facility was cited for failing to accurately submit direct care staffing information and failed to ensure the QAPI program was sustained during transitions in leadership to maintain implemented procedures during an annual recertification survey on 4/18/24 and was cited again for the same deficiencies during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for two (2) of (11) deficiencies cited. F851 and F865/867. Findings Include: Review of the facility's policy, Performance Improvement (QAPI), dated 6/1/25, revealed, .The Center and organization have an ongoing Performance Improvement Program with a design and scope that is ongoing and comprehensive.The design and scope of the program is to systematically monitor and evaluate the quality and appropriateness…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a resident's right to dignity and respect when staff required her to wear a brief against her preference instead of providing a bedpan or assistance to the bathroom for one (1) of (22) sampled residents, Resident #109.Findings include:On 9/9/25 at 11:05 AM, in an interview, Resident #109 reported that the night shift staff told her she would need to wear a brief rather than being assisted to the bathroom or put on a bedpan, despite her reporting that she does not wear briefs.On 09/10/2025 at 4:15 PM, during an interview with Licensed Practical Nurse (LPN) #1, she explained that Resident #109 was already admitted to the facility when she came on shift and she recalled that she thought the resident was wearing a pull-up at that time, and she suggested that a brief might be easier than a pull-up since it would not require pulling up and down. LPN #1 confirmed that the evening shift staff, including herself, used a bedpan for the resident, and she personally assisted the resident onto the bedpan, which she tolerated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to honor a resident's request for assistance in obtaining personal identification, resulting in a delay of more than one (1) year without follow-up affecting her autonomy and ability to exercise her rights related to personal identification and community access for (1) of (22) sampled residents, Resident #48. Findings include:On [DATE] at 12:31 PM, in an interview, Resident #48 stated she had requested assistance from the facility in completing paperwork and obtaining a state identification (ID) card but that her request had not been fulfilled.On [DATE], at 8:34 AM, during an interview, the Social Services Director stated she had no knowledge of Resident #48's request for assistance with obtaining an ID. She reported the resident frequently brought her insurance mail but had not made the ID request directly to her, acknowledging that the resident may have told the Social Services Assistant instead.On [DATE] at 10:50 AM, during an interview, Social…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · tag F0572 — isolatedGive residents a notice of rights, rules, services and charges.
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, interviews, and resident council interview, the facility failed to provide residents or their resident representatives (RRs) with copies of the Resident [NAME] of Rights and admission documents at the time of admission, with the potential to affect all newly admitted residents by depriving them of required information about their rights and responsibilities upon admission for one (1) of 22 sampled residents (Resident #26).Findings include:A review of the facility's admission Agreement revised 5/25, revealed that Section #20 (items a-o) requires residents or their representatives to sign acknowledging receipt of copies received including the Resident [NAME] of Rights, Resident Handbook, and other admissions documents.On 9/8/202 at 2:00 PM, during a resident council meeting, Resident #26 stated she did not recall receiving admission information during the admission process. She stated she was admitted to the facility on [DATE].On 9/10/25, at 4:45 PM, an interview with the admissions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to personal privacy by posting identifying hospice information on a resident's door for one (1) of 22 sampled residents. Resident #85.Findings include: A review of the facility's policy, Resident Rights dated 11/30/2014, revealed . The Facility will not use or disclose the resident's health information without the Resident's authorization.On 9/8/25 at 10:26 AM, during an observation of Resident #85's room, signage was posted on the resident's door sign labeled (Proper Name of Hospice Provider) with the resident's first initial and last name highlighted in yellow stated Call (Proper Name of Hospice Provider) First. Resident #85 was lying in bed and was unable to verbalize awareness of hospice services or knowledge of the signage posted on her door.On 9/8/25 at 12:40 PM, during a phone interview with Resident #85's resident representative (RR), she reported that she had not requested the hospice sign to be placed on her mother's door. She explained that the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop 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 staff interview, record review, facility investigation and facility policy review, the facility failed to implement its abuse prevention policy by not reporting and investigating an allegation of misappropriation of resident property in a timely manner for one (1) of 22 sampled residents, Resident #106.Findings Include:A review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation, revised 11/16/2022, revealed, .7. Reporting/Response: Any employee or contracted service provider who.has knowledge of.an allegation of.misappropriation of resident property.is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.Once an allegation of abuse is reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations . Review of report: Report the results of all investigations to the Executive Director or his or 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.
Show the remaining 17 citations
- Potential for harm · Dcited before2025-09-11 · 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, interview, record review, and facility policy review, the facility failed to provide assistance with activities of daily living (ADLs) for residents who are dependent upon staff, related to incontinence care (Resident #109) and shaving (Resident #91) for two (2) of 22 sampled residents.Findings include:A review of the facility's policy, Activities of Daily Living (ADLS) dated 02/01/2022, revealed . To encourage resident choice and participation in activities of daily living (ADL) and provide.assistance as necessary . ADLs includes bathing, dressing, grooming, hygiene, toileting . Procedure.2. CNA (Certified Nurse Aide) will provide needed . assistance to resident.Resident #109On 9/9/25 at 11:05 AM, during an interview, Resident #109 reported she had been left in a soiled brief since 6:00 AM. She stated she pushed the call light several times, but staff turned the light off without returning to provide care. The resident's daughter, present at the time, confirmed she arrived at 9:00 AM, remained until 10:10 AM, returned at 10:30 AM, and no staff had checked 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 · Dcited before2025-09-11 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and facility policy review, the facility failed to prevent the possible spread of infection by not implementing contact isolation precautions timely for (Resident #47) and enhanced barrier precautions (EBP) when providing care for (Resident #4) for two (2) of 22 sampled residents.Findings include:A review of the facility's Policies and Practices - Infection Control, revised October 2018, revealed, This facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections. Policy Interpretation and Implementation.2. The objectives of the infection control policies and procedures are to: a. Prevent, detect, investigate, and control infections in the facility b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public c. Establish guidelines for implementing Isolation…
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 · Fcited before2024-04-18 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, record review, and facility policy review, the facility failed to accurately submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid (CMS) as required for Quarter 1 of Fiscal Year (FY) 2023 (October - December 2023) for one (1) of five (5) quarters reviewed. Findings include: Record review of facility's policy Staffing Requirements, effective 11/30/2014, revealed, .Purpose .To provide a sufficient number of employees . A review of the Payroll Based Journal (PBJ) Staffing Data report from the Certification and Survey Provider Enhanced Reports (CASPER) database for FY Quarter 1 (October 1-December 31) revealed the Metric of Excessively Low Weekend Staffing was triggered related to .Submitted Weekend Staffing is excessively low. Record review of the facility PBJ Data entry report for October, November, and December of 2023 revealed PBJ Salaried Employee Hour Adjustments occurred for the Minimum Data Set (MDS) Staff RN and the adjustments did not occur on weekends or for any other facility salaried employees. 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 · Dcited before2024-04-18 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right for a dignified dining experience when the staff did not provide incontinence care for a resident which resulted in odors in the resident's room, causing the meal to be unappetizing, for one (1) of 22 sampled residents. Resident #38 Findings include: A review of the facility's policy Resident's Rights and Responsibilities, effective 01/07 revealed .Each nursing facility resident has a right to a dignified existence .A facility must protect and promote the rights of each resident . On 4/15/24 at 12:17 PM, during an observation in the hallway, Resident #38's call light was lit up above the door. Certified Nurse Aide (CNA) #2 walked into the resident's room, explained to the resident that it would be a minute because she was passing out meal trays, and she exited the room. There were no meal trays being served on the hall at that time. On 4/15/24 at 1:10 PM, during an interview and observation, Resident #38 was lying in bed. There was a strong odor in the room.…
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 before2024-04-18 · 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
Based on interviews, record reviews, and facility policy review, the facility failed to develop care plan interventions for a resident with a Urinary Tract Infection (UTI) (Resident #55) and for a resident with Substance Use Disorder (SUD) (Resident #57), and failed to implement a care plan intervention related to a low air loss mattress (Resident #261) for three (3) of 22 resident care plans reviewed. Findings include: A record review of the facility's policy Plans of Care with revision date 09/25/17 revealed . An individual person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative (s) to the extent practicable and updated in accordance with state and federal requirements . Resident #55 On 4/15/24 at 10:55 AM, during an interview, Resident #55 explained he had a UTI and was taking medication for the UTI. Record review of the admission Record revealed the facility admitted Resident #55 on 9/1/22 and had current diagnoses including Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease.…
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 before2024-04-18 · 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
Based on interviews and record review the facility failed to ensure a resident's safety by not assessing for the risk of substance use and not developing interventions for a resident with known substance use disorder (SUD) for one (1) of 22 sampled residents. (Resident # 57) Findings include: During an interview on 4/15/24 at 1:00 PM, Resident #57 stated that he frequently signed himself out of the facility to visit a friend that lived down the street. He confirmed he used his electric wheelchair to travel beside the road to his friend's home. He commented that the facility was trying to discharge him from the facility because he enjoyed visiting his friends outside of the facility. The resident confirmed he would drink a couple of beers while visiting his friends sometimes but denied bringing alcohol or tobacco back into the facility. During an interview on 4/16/24 at 9:00 AM, Resident #57's family member revealed Resident #57 had a history of alcohol abuse since he had an accident which caused him to become paralyzed from the waist down. The family member commented that the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-18 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolatedHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, record review, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to ensure the program was sustained during transitions in leadership and failed to maintain implemented procedures and monitor the interventions the committee put into place in April 2022. This was for two (2) recited deficiencies originally cited in April 2022 on an annual recertification survey. The deficiencies were in the area of residents' rights and wounds. The facility's continued failure during two surveys shows a pattern of the facility's inability to sustain an effective QAPI Committee for two (2) of eight (8) deficient practice citations. Findings Include: A record review of the facility's policy, Quality Assurance Performance Improvement Program (QAPI), with a revision date of 10/24/2022, revealed, Policy: The Center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life .Program Design and Scope…
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 before2024-04-18 · 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, staff interview and facility policy review, the facility failed to prevent the possible spread of infection as evidenced by a nurse touching medications with her bare hand and Certified Nursing Assistants (CNAs) discarding soiled linens and briefs on the floor for three (3) of nine (9) medication and incontinence care observations. Findings include: Medication Administration Review of the facility's policy Medication- Oral Administration Of, revised 8/15/2019, revealed, Procedure .Refrain from touching powders, capsules, or pills with hands . On 04/16/24 at 8:59 AM, during a medication administration observation, Registered Nurse (RN) #3 placed a resident's pill into her ungloved hand and placed it in a medication cup. On 04/16/24 at 10:59 AM, during an interview with RN #3, she confirmed she had placed a resident's pill in her ungloved hand and then put it in a medication cup because it was easier that way. She said she knew that it was not right, and it was not the way she was trained to administer medications. She stated it was a break in infection control.…
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 before2024-04-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility policy review, the facility failed to ensure a Pressure Ulcer (PU) intervention related to an air mattress was continued after a room change for one (1) of three (3) residents reviewed for PUs. Resident #261 Findings include: Review of the facility's policy, Skin and Wound revised 1/24/22, revealed, .To provide a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention and healing of pressure injuries .Process .Pressure Injury Mitigation Strategies .Develop resident centered interventions based on resident risk factors . Record review of the Braden Scale dated 10/17/23, revealed Resident #261 had a score of 17, which indicated he was at risk for PUs. Record review of the Order Summary Report revealed Resident #261 had a Physician's Order, dated 10/26/2023 for a low air loss mattress. During an interview on 4/16/24 at 1:00 PM, with a family member of Resident #261, she explained she attended a care plan meeting with the facility and the Medical Doctor (MD) apologized to her 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 · Dcited before2022-04-29 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record review and facility policy review the facility failed to treat a resident in a dignified manner by not covering the resident during incontinence/catheter care for one (1) of eight (8) care observations. (Resident #77) Review of the facility's Policies and Procedures with the Subject of Perineal Care with a revised date of 9/5/2017 revealed, Procedure .Remove necessary clothing .Wash, rinse and dry the skin, being certain to expose all skin surfaces which are soiled . On 04/26/22 at10:07 AM, the State Agency (SA) observed incontinent/catheter care with Certified Nursing Assistant (CNA) #8 for Resident #77. Her husband remained in the room for the procedure. CNA #8 pulled the residents gown up, pulled the cover down, and exposed her perineal area. CNA #8 then went to the sink and filled the water basin, leaving the resident exposed. Resident #77 pulled her gown back down to cover herself. CNA #8 then returned to the resident to perform incontinent/catheter care. CNA #8 pulled the gown up and asked the resident to open her legs. CNA #8 cleansed…
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 · D2022-04-29 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review and facility policy review, the facility failed to resolve a resident's grievance regarding personal property for one (1) of three (3) residents reviewed for misappropriation of property. Resident #20. Record review of the facility's Clinical Guideline - Complaint/Grievance with a revision date of 8/9/2018, revealed, .Purpose: To support each resident's right to voice grievances; resulting in a follow-up and resolution while keeping the resident apprised of its progress toward resolution .Process . The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days . The individual voicing the grievance shall receive follow up communication with the resolution . Record review of Resident #20's admission Record revealed he was admitted by the facility initially on 7/30/21 and had a recent re-admission date of 1/11/22. He had diagnoses including Acute on Chronic Systolic (Congestive) Heart Failure, Essential Hypertension, and Acute Kidney failure. Record review of the Minimum Data Set (MDS) with an Assessment…
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 · D2022-04-29 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 thoroughly investigate a resident's allegation of misappropriation of personal property for one (1) of three (3) residents reviewed for misappropriation of property. (Resident #20) Record review of the facility's policy, Protection of Resident's Personal Property, (undated) revealed, Policy .6. The Administrator or his/her designee will log the missing items, complete an investigation on all missing items and document results of findings .The Administrator will ensure that the resident/ responsible parties informed of the results of the investigation . On 04/25/22 at 03:00 PM, Resident #20 stated that he was missing a gold ring with three diamonds in it. He put his ring in the bedside nightstand in the drawer and the end of last year (2021) and it was gone when he went to look for it. He described the Social Services Designee (SSD) and said he had told her his ring was missing. He stated the ring was missing it was the end of last year. On 04/28/22 at 02:46 PM, in an interview with the SSD, she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-04-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and facility policy review the facility failed to ensure residents who were dependent on staff for showering, shaving, and nail care received those services for five (5) of six (6) residents reviewed for Activities of Daily Living (ADLs) assistance. Resident #48, Resident #49, Resident #56, Resident #58, and Resident #60. Review of the faciality's Policies and Procedures with the Subject of Bathing/Showering, revised on 9/1/2017, revealed Policy: Assistance with showering and bathing will be provided at least twice a week and PRN to cleanse and refresh the resident. The resident shall be asked on admission to establish a frequency schedule for bathing. This schedule will take precedence over the twice a week and PRN cleansing . Review of the facility's Policies and Procedures with the Subject of Podiatry, revised on 8/24/2017 revealed, Policy: Podiatry consults are available to residents in need of services other than routine care. Procedure .The consulting…
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 before2022-04-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY F686 Based on observation, interview, record review and facility policy review the facility failed to clean a residents wound according to professional standards for two (2) of four (4) wound care observations Resident #49 and Resident #63. Findings include: A record review of the facility's Policies and Procedures with the Subject of Clinical Guideline Skin & Wound with an effective date of 4/1/2017 revealed, Overview: To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing, and decrease worsening of/prevention of pressure injury. Process: . monitor residents' response to treatment and modify treatment as indicated . A record review of the facility's Policies and Procedures with the Subject of Dressing Change with revision date of 12/6/2017 revealed Policy: A clean dressing will applied by a nurse to a wound as ordered to promote healing Procedure: Cleanse wound as ordered, dispose of gauze .…
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 · D2022-04-29 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 prevent a significant medication error when a resident did not receive sliding scale insulin per physician's orders for one (1) of two (2) residents reviewed. Resident #234. Findings include: A record review of the facility's Policies and Procedures with a Subject of Blood Glucose Monitoring and Disinfecting with a revision date of 3/1/2021, revealed Procedure: Verify Physician order . A record review of the facility's policy Administering Medications with a revised date of April 2019 revealed, Policy Medications are administered in a safe and timely manner, and as prescribed . A record review of Resident #234's admission Record revealed the facility admitted Resident #234 on 4/19/2022 with diagnoses including Pneumonia and Type 2 Diabetes Mellitus with Hyperglycemia. A record review of Resident #234's Order Summary Report revealed an order dated 4/20/22 for Blood glucose before meals and at bedtime (ACHS) and an order dated 4/20/22 for Novolog solution 100 units/milliliter (ml) inject…
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 before2022-04-29 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, record review and facility policy review the facility failed remove expired food items from the pantry, failed to date open food items and failed to reseal a hamburger bun package for one (1) of three (3) kitchen observations. Record review of the Facility's Policies and Procedures with the Subject as Dry Food Storage, dated 11/30/2014, revealed, Policy: To prevent damage, infestation and spoilage of food and maintain quality food products .Procedure: . Open packages will be stored in closed containers or secured with metal ties, etc. and dated . On 04/25/22 at 010:30 AM, an initial observation of the kitchen with the Regional Dietary Director (RDD) revealed a bag of hamburger buns torn open and exposed to air on the bread cart. There were 2 containers of thickened apple juice with expiration dates of 4/12/22 and 4/15/22. The following food/items did not have date they were initially opened for use: a 1-gallon container of sweet and sour sauce, half full., a 1-gallon container of worcestershire sauce, a 10-ounce bottle of sweet and sour sauce, and 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.
- No harm found · C2025-09-11 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, the facility failed to post daily nurse staffing information in a prominent place readily accessible to residents, staff, and visitors for four (4) of (4) days of survey, which had the potential to affect all 108 residents residing in the facility.Findings include:On 9/8/25 at 10:00 AM, during an initial tour of the facility, there was no daily staffing information posted throughout the building. There was a stop sign on the entranceway door asking staff and family not to allow residents beyond the double doors into the entrance hall.On 9/9/25 at 8:00 AM, during a walkthrough of the facility, the State Agency (SA) did not observe the required daily posting of staffing information.On 9/10/25 at 9:00 AM, during a walkthrough of the facility, the SA did not observe the required daily posting of staffing information.On 9/11/25 at 11:55 AM, during an interview, Licensed Practical Nurse (LPN) #4 stated that the staffing was usually taped on the table in the entrance hallway next to the visitor sign-in book. LPN #4 confirmed she failed to tape 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.
“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
$22,410 in federal fines across 3 penalties.
- $5,181 — penalty dated 2025-02-13
- $5,181 — penalty dated 2025-02-13
- $12,048 — penalty dated 2024-04-18
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to CONSULATE HEALTH CARE/INDEPENDENCE LIVING CENTERS/NSPIRE HEALTHCARE/RAYDIANT HEALTH CARE — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.8 | -0.8 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 4 of 5 | 3.5 | +0.5 vs chain |
| Quality measures | 3 of 5 | 2.9 | +0.1 vs chain |
The other 10 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| FGLFC HOLDCO, LLC | Organization | DIRECT OWNERSHIP INTEREST | since 04/01/2022 |
| FC INVESTORS XXI LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 04/01/2022 |
| LAVIE HOLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 04/01/2022 |
| LV INVESTMENT LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 04/01/2022 |
| NSPR CARE CENTERS, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 04/01/2022 |
| NSPR OPERATIONS I, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 04/01/2022 |
| NSPR OPERATIONS II, LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 04/01/2022 |
| HOBACK, TIFFANY | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 06/01/2025 |
| SNF MGR LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/03/2026 |
| ALBERT, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/09/2022 |
| WILLIAMS, JAMES | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/04/2024 |
| WINKLE, ASHLEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2023 |
CMS files one row per role, so the 17 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
8 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $566K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Mississippi Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 255142. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-11, 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.