Neshoba County Nursing Home
1001 Holland Avenue, Philadelphia, MS 39350 · Government - County · 145 certified beds · (601) 663-1200 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — 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 (F0565)
- 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 (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $15,945 in federal fines (most recent 2026-02-03)
- 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) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 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 2 to 3 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 | 12.4% | 20.5% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.2% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.0% | 1.4% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.2% | 2.5% | 2.0% | worse |
| 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 | 5.1% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.4% | 19.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.1% | 23.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 6.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 7.2% | 20.7% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 45.5% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 2.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.2% | 84.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.3% | 27.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.8% | 15.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.21 | 2.43 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.72 | 2.86 | 1.80 | typical |
* 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.
63.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 192 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 24.2% 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 91 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 0.20 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 63.1%CMS range 57.0–67.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.1%CMS range 6.4–12.8 | 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 | 24.2% | 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 | 27.5% | 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 | 22.0% | 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 | 0.8% | 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 | 97.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 92.9% | 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 | 2.3% | 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 | 6.2%CMS range 3.7–9.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.73 | 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 145 beds and averages 128.9 residents a day — about 89% occupied, or roughly 16 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 4.48 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.446 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 3.77 hrs/resident/day on weekends vs 4.77 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.08 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-02-03 · 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, record reviews, facility policy reviews, and the facility's investigation, the facility failed to provide adequate supervision to prevent residents who were identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for two (2) of 19 residents residing on the secured Alzheimer's unit. Resident #1 and Resident #2. On 1/20/26 at approximately 1:32 PM to 1:35 PM Resident #1 entered the door alarm code and Resident #1 and Resident #2 exited the facility undetected by staff. Resident #1 was unattended and unsupervised until located by law enforcement 29 miles from the facility and returned to the facility at 3:50 PM. Resident #2 was identified by staff to be outside on facility property and was assisted back into the facility at 1:48 PM. The elopement placed Resident #1, Resident #2, and other residents at risk for wandering and elopement, in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. During the investigation, the SA identified an Immediate Jeopardy (IJ) and Substandard…
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 before2025-11-18 · 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, interview, record review, and facility policy review, the facility failed to ensure the kitchen equipment and surrounding areas were maintained in a clean and sanitary condition for two (2) of three (3) kitchen tours. Findings Include Record review of the facility policy titled, General Sanitation of the Kitchen undated, revealed The staff shall maintain the sanitation of the kitchen through compliance with a written comprehensive cleaning schedule.4. A cleaning schedule will be posted. Employees will be trained on the cleaning schedule and how to perform duties. Employees will initial and date tasks when completed . During the initial kitchen tour on 9/29/25 at 12:20 PM, observation of the deep fryer revealed a thick yellow and black substance with food particles built up down the entire right side of the fryer. The left side of the stove had splattered buildup, and underneath the fryer was a thick, greasy substance with food particles extending across the surrounding floor. On 10/01/25 at 9:15 AM, during an interview and concurrent observation, the Dietary…
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 · D2025-11-18 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and facility policy review, the facility failed to ensure that the use of a bed alarm did not constitute a physical restraint for one (1) of four (4) residents reviewed for restraints (Resident #62). Findings Include: Review of the facility policy titled, Restraint Free Environment with an approval date of 6/27/2025 revealed, Each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience, and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. An observation and interview on 9/29/25 at 1:15 PM with Resident #62, revealed the resident lying in bed with her hands clenched, body appearing stiff and her bed alarm was sounding despite only slight movement. She stated, If I misbehave, this thing beeps, I have to be still. The alarm kept sounding and Licensed Practical Nurse (LPN) #5. entered the room and adjusted the bed alarm without success. She removed it and placed another…
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 before2025-11-18 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and facility policy review, the facility failed to implement a care plan for Activities of Daily Living (ADLs) (Resident #5, #64, #105), wandering (Resident #57), gastrostomy (Resident #64), and therapeutic diet (Resident #134) for five (5) of 26 resident care plans reviewed. Resident #5, #57, #64, #105, and #134 Findings Include Review of the facility policy titled, Comprehensive Care Plan undated revealed under Policy.It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #5 Record review of Resident #5's LTC (Long Term Care) ADL (Activities of Daily Living) Function 2 (Two) Plan revealed that she required extensive assistance with bed mobility, transfer, dressing, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-18 · 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 Activities of Daily Living (ADL) care related to nail care (Resident #64, Resident #105) and shaving (Resident #5) for 3 (three) of 50 sampled residents. Findings Include: Review of the facility policy titled Activities of Daily Living revealed under Policy Explanation and Compliance Guidelines: .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #5 On 9/29/25 at 3:38 PM and again on 9/29/25 at 3:58 PM Resident #5 was observed with multiple scattered gray chin hairs that measured approximately one-half (1/2) inch. She was pleasantly confused and unable to answer simple questions. On 09/30/25 at 2:38 PM, an observation and interview with Resident #5 and Licensed Practical Nurse (LPN #1) confirmed that the resident had multiple gray hairs on her chin. She admitted that the resident's facial hair should have been removed when she received her bath and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-18 · 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 observation, staff interview, record review, and facility policy review, the facility failed to ensure that a resident identified as an elopement risk had the physician prescribed wander alert bracelet applied for one (1) of four (4) residents reviewed for accident hazards. Resident #57 Findings Include:Review of the facility policy titled Code Alert Policy, unrevised, revealed under Policy: To prevent wandering residents from leaving the facility or attempting to leave the facility by alerting the nursing staff of their exit through the doors . Procedure: Wandering residents who are deemed to be a Flight Risk will have a code alert bracelet placed on their wrist or ankle.The staff nurse will check each transmitter and the door each shift and document on the code alert TAR (treatment administration record) in the EHR (electronic health record) if the transmitters and doors are functioning correctly .An observation and interview with Resident #57 on 9/29/25 at 12:40 PM revealed she was sitting in her recliner in her room reading a book with a wander alert bracelet lying on a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-18 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure proper placement of a gastrostomy tube prior to medication administration for one (1) of two (2) enteral tubes reviewed. Resident #64 Findings Include:Review of the facility policy titled Enteral Tube Medication, unrevised, revealed under Policy Explanation and Compliance Guidelines: 8. Enteral tube placement must be checked via auscultation and/or aspiration before any fluids or medication are administered.During an observation on 9/30/25 at 12:10 PM with Resident #64, Licensed Practical Nurse (LPN) #5 flushed the resident's enteral tube with water and administered medications without first verifying placement of the tube.An interview with LPN #5 on 9/30/25 at 12:21 PM confirmed that she did not check placement of Resident #64's enteral tube prior to administering medications and that it should have been done to ensure the tube was in the proper place to prevent aspiration. She admitted that the nursing staff was supposed to follow standards of practice by aspirating…
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 · D2025-11-18 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure the safe storage and security of medications for one (1) of 128 residents reviewed during initial tour. Resident #101 Findings Include: Review of the facility policy titled General Rules for Residents and Sponsors (undated) revealed under section .5: Residents are not permitted to keep any medications in their room unless the interdisciplinary team has determined that this practice is safe and ordered by the physician.An observation and interview with Resident #101 on 9/29/25 at 12:42 PM revealed she was lying in bed with a Symbicort inhaler and a Spiriva inhaler lying on a table in the room. Resident #101 stated the nurse had forgotten to come back and get them after she took them that morning.Record review of the Medication Administration Record (MAR) revealed an order dated 7/14/25, Tiotropium (Spiriva Respimat) 1.25 mcg(microgram)/INH (inhalation aerosol), inhale 2 puffs daily. The MAR also revealed an order dated 7/22/24, Budesonide-formoterol 80 mcg…
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 · D2025-11-18 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 a prescribed therapeutic diet for one (1) of 50 sampled residents. Resident #134.Findings Include: Review of the facility policy titled, Thickened Liquids revealed, It is the policy of the (proper name) facility that residents receive liquids as they are ordered and recommended by their physician and or speech language pathologist. An observation and interview on 09/30/25 at 11:32 AM of Resident #134's lunch meal revealed that he had nectar thickened water, nectar thickened sweet tea, and a carton of regular consistency creamy strawberry Glucerna on his tray. An observation also revealed Certified Nursing Assistant (CNA) #2, open his Glucerna and insert a straw into the container for him to drink. CNA #2 confirmed that the Glucerna was not nectar consistency like the water and sweet tea. During an observation and interview on 09/30/25 at 11:36 AM in Resident #134's room with Registered Nurse (RN) #1, she confirmed that the Strawberry Glucerna that was on Resident #134's meal…
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 · D2025-11-18 · 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 observations, interviews, record review and facility policy review, the facility failed to ensure the possibility of the spread of infection by respiratory equipment not being stored properly for one (1) of two (2) residents observed receiving nebulizer treatments (Resident # 53). Findings Include Review of the facility policy titled Nebulizer Therapy with an approval date of 8/06/25 revealed, It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. An observation on 9/29/25 at 4:30 PM and again on 9/30/25 at 1:45 PM revealed Resident #53's nebulizer was sitting on top of the resident's oxygen concentrator with the mouthpiece uncovered and not stored in a clean or protected manner. During an observation and interview with the Clinical Services Director on 9/30/25 at 3:30 PM, she confirmed that Resident # 53's mouthpiece was not stored properly. She stated that It should be covered, stored in a clean bag or container because leaving it out like that could cause…
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 · D2024-03-25 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and policy review, the facility failed to prevent verbal abuse to Resident #1 for one (1) of three (3) residents reviewed for abuse/neglect. Findings Include: The facility policy titled Abuse, Neglect, and Exploitation dated approved 03/04/2025 read: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. Interview on 03/25/24 at 12:20 PM with the facility Administrator revealed that Hospital Dietary Employee #1 and Resident #1 had words in the dining area a few weeks ago when the resident had returned to the facility from being out on a pass. He stated the resident was requesting food in the dining room area of the facility when this incident…
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 12 citations
- Potential for harm · Fcited before2023-12-15 · 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 interviews, and facility policy review, the facility failed to ensure food items in the kitchen refrigerators were dated and labeled and failed to ensure kitchen equipment was clean for two (2) of three (3) kitchen tours. Findings Include: Record review of the facility policy titled, Food Storage undated, revealed Food is stored, prepared and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination .13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. f .Meat, fish, and poultry should be stored on lower shelves . Record review of the facility policy titled, Ice undated, revealed, Ice will be produced and handled in a manner to keep it free from contamination .2. Ice machines will be maintained in a clean and sanitary condition to prevent ice contamination. Record review of the Weekly Cleaning Schedule, undated, revealed under Task to be completed, 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 · E2023-12-15 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, resident and staff interviews, record review and facility policy review, the facility failed to address a grievance discussed in resident council for the use of bed rails for five (5) of 12 residents that attended resident council. Resident #15, Resident #27, Resident #37, Resident #61, and Resident #66. Findings Include: Record review of the facility policy titled Resident and Family Grievances undated revealed under, Policy Explanation and Compliance Guidelines: . 8. Grievances may be voiced in the following forums: . d. Verbal complaint during resident or family council meetings . An interview with the Resident Council President (Res #27) on 12/12/23 at 12:25 PM, revealed that the residents had discussed the facility's removal of the bed rails during a previous meeting. She revealed that most of the residents want them back so that it would make it easier for them to move from side to side and turn themselves in the bed. Record review of the Resident Council meeting minutes dated 11/01/23 revealed 12 residents discussed being upset about rails being taken…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide dignity to residents as evidenced by leaving urinary catheter bags uncovered for two (2) of five (5) residents with a catheter. Resident #24 and Resident #89. Findings Include: Review of facility policy titled, Resident Rights, revealed, The resident has the right to a dignified existence .8. Privacy and confidentiality: The resident has a right to personal privacy . Review of a statement on facility letterhead dated 12/14/23 and signed by the Director of Nursing (DON) revealed, We do not currently have included in our policy that catheter bags have to be covered in dignity bag. Resident #24 An observation and interview on 12/12/23 at 12:01 PM, revealed Resident #24 sitting in her wheelchair. A urinary catheter bag with no privacy cover was observed hanging on the bottom of the back of the wheelchair. Observation and interview on 12/13/23 at 2:55 PM, observed Resident #24 lying in bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-15 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, record review and facility policy review the facility failed to accommodate a resident's mobility needs for (2) two of (3) three sampled residents reviewed for mobility needs. (Resident #82, and #83) Findings include: Review of the facility policy titled, Use of Assistive Device, revealed Policy: The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity. Policy Explanation and Compliance Guidelines: 1.) Assistive devices are tool, products, types of equipment, or technology that may help individuals perform tasks and activities . Resident #82 An interview and observation on 12/12/23 at 11:10 AM, revealed the resident has a bariatric bed with no side rails. The resident stated, I used to have half rails on my bed, and I could use them to pull myself up and around in the bed, but the facility took my rails off of my bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-15 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, and facility policy review, the facility failed to implement a care plan for a trapeze bar for (Resident #81), a side rail use care plan for (Resident #1), and a care plan for two handle adaptive cups for (Resident #41 and Resident #60) for four (4) of 29 resident care plans reviewed. Findings include: Review of the facility policy titled, Comprehensive Care Plans, revealed Policy: It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that identified in the resident's assessment . Resident #1 Review of the care plan titled, LTC (Long-Term Care) Falls IPOC (Individual Pan of Care), last updated 9/28/23, revealed Interventions: upper side rails ½ x (time) (2) two activated 9/28/23 . On 12/12/23 at 10:30 AM an observation revealed Resident #1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-15 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, record review and facility policy review the facility failed to follow physician orders for a resident with side rails for one (1) of 27 sampled residents (Resident # 1). Findings include: A statement provided on facility letter head revealed, We do not currently have a policy on Following Physician Orders. Review of the Job Summary for Registered Nurses (RN) and Licensed Practical Nurse (LPN) provided by the Administrator in Training revealed, Duties and Responsibilities: Follows physician's orders in giving nursing care. An observation on 12/12/23 at 10:30 AM revealed Resident #1 lying in bed with side rails up times four (4). A review of the LTC (Long-Term Care) Order Review /Renewal Form revealed a physician's order for Resident #1 dated 9/28/23, upper side rails 1/2 x 2 (two) due to DX (diagnosis) of seizures and cerebral palsy with spastic involuntary movements. Review of the Bed Rail Use Assessment Form dated 9/8/23 and 12/5/23 for Resident #1 revealed, Recommended type: ½ length rail -left, right upper. A review of the physician's orders for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, record review and facility policy review the facility failed to accommodate a residents mobility needs for (1) one of (3) three sampled residents reviewed for mobility needs. Resident #81 Findings include: Review of the facility policy titled, Use of Assistive Device, revealed, Policy: The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity . Policy Explanation and Compliance Guidelines: 1.) Assistive devices are tool, products, types of equipment, or technology that may help individuals perform tasks and activities . An interview with Resident #81 on 12/12/23 at 11:28 AM, he revealed the first part of November someone came and took his side rails off and stated he used the rails to help the staff with turning and positioning him and the staff said they can't use bed rails anymore. An observation at that same time revealed no side…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident and staff interview, record review and facility policy review the facility failed to accommodate hydration needs for a resident when a water pitcher was not in accessible reach of the resident for (1) one of 109 residents with water pitchers. (Resident # 50) Findings include: Review of the facility policy titled, Hydration, revealed Policy: Water will be placed where it is easily accessible to the resident. During an observation down Hallway 1 on 12/12/23 at 10:25 AM, Resident #50 was overheard hollering out for help from his room. Upon entering the room Resident #50 was observed sitting in a reclining wheelchair. When asked if he needed help, the resident stated, I need some water. The water pitcher was located on a bedside table that was across the room from where the resident was sitting in his chair. The State Agency went directly to the nurse station and notified a staff member that Resident #50 requested a drink of water. She replied, We'll get him some. During the continued initial survey rounds on 12/12/23 at 10:45 AM, Resident #50 was heard from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-15 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and facility policy review the facility failed to provide a PEG (percutaneous endoscopic gastrostomy) tube feeding as ordered for one (1) of five (5) residents with PEG tubes observed during survey. Resident #54. Findings include: A review of the facility policy titled Standard Guidelines for Enteral Nutrition, revealed, .Provide the enteral feedings as ordered. An observation, on 12/13/23 at 7:30 AM of Resident #54's feeding pump at bedside, is observed as being turned off at that time. No feeding was infusing at the current time and the bag was empty. The feeding bag hanging had the date of 12/12/23 and 1700 written on it. An interview, on 12/13/23 at 7:35 AM with Licensed Practical Nurse (LPN) #1 confirmed that the bag hanging had 12/12/23 1700 written on it and that it is empty and that the pump is cut off. LPN #1 confirmed that the resident not having his feeding could cause him to be dehydrated or have weight loss. A record review of Resident #54's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-15 · tag F0810 — isolatedProvide 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 observation, staff interviews, record review and facility policy review, the facility failed to provide a resident with a handled cup for drinking during mealtime for two (2) of eight (8) residents observed with adaptive equipment for dining. Resident #41 and Resident #60 Findings Include: Record review of the facility policy titled Adaptive Eating Devices undated revealed, Policy: Adaptive eating equipment devices are available for those residents needing them . Adaptive devices in use are sanitized and provided for each meal. Adaptive devices are noted on each resident Tray Ticket and in the medical record . Resident #60 Record review of Resident #60's lunch meal ticket provided with the meal dated 12/12/23 revealed, Handled cup with lid. An observation of Resident # 60 during a lunch meal on 12/12/23 at 11:52 AM, revealed the resident feeding herself ice cream. 8 ounces of iced tea and water provided in a clear plastic cup, along with a 12 ounce can of sprite and a bottled Ensure. The observation did…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-25 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interviews and record review the facility failed to provide the resident/resident representative with a written notice of transfer/discharge to the hospital for four (4) of (4) residents reviewed. Resident's #66, #67, #78 and #84. Findings Include Resident # 67 Record review of a typed statement on facility letterhead, signed by the Director of Nursing (DON) revealed, On August 24th, 2022, our Facility did not have a Written Transfer/discharge notice policy and/or form for resident being transferred/discharged from our facility. An interview with the Director of Nursing (DON) on 08/23/22 at 2:55 PM revealed Resident #67 was taken to the hospital on [DATE]. An interview with the DON on 8/24/22 at 10:25 AM, revealed the resident was transferred to the hospital. She confirmed the facility failed to provide a written notification of transfer to the resident's representative as required in the regulations. She revealed she was unaware of the requirement for a written notification of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2023-12-15 · tag F0625 — widespreadNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, record review and facility policy review the facility failed to provide written notification to the resident/representative regarding bed hold when the resident was sent to the hospital for four (4) of 4 residents reviewed for hospitalization. Resident #24, Resident #54, Resident #87, and Resident #94 Findings include: A record review of a statement on facility letterhead written by the Director of Nursing and dated 12/15/23, revealed, Our bed hold policy doesn't include to mail a copy to Responsible Party (RP) for transfer/discharge. Resident #24 Record review of Resident #24's Nursing Narrative Note dated 09/14/23 revealed Nurse Practitioner (NP) ordered to direct admit Resident #24 to local hospital with dx(diagnosis) of Chronic Renal Failure. An interview on 12/15/23 at 8:05 AM, the Social Services Director revealed she mailed the transfer/discharge form to the resident but did not mail out the bed-hold notice with the amount to hold the bed. She confirmed Resident #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.
“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
$15,945 in federal fines across 1 penalty.
- $15,945 — penalty dated 2026-02-03
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| NESHOBA COUNTY GENERAL HOSPITAL | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/22/2009 |
| WARD, GLENDA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | NO PERCENTAGE PROVIDED | since 02/10/2025 |
| MCNAIR, SCOTT | Individual | CORPORATE OFFICER | — | since 01/01/2016 |
| POSEY, MARSHALL | Individual | OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF | — | since 04/20/2016 |
| BRAZZLE, RUBY | Individual | TRUSTEE OF THE SNF | — | since 12/05/2011 |
| DALY, JO HELEN | Individual | TRUSTEE OF THE SNF | — | since 12/15/2011 |
| JOLLY, OLIVER | Individual | TRUSTEE OF THE SNF | — | since 09/16/2009 |
| JOYNER, DALE | Individual | TRUSTEE OF THE SNF | — | since 01/15/2020 |
| BEALE, STEFANI | Individual | ADP OF THE SNF | — | since 04/14/2025 |
CMS files one row per role, so the 13 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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.
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 255137. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-18, 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.