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Ruleville Community Care Center

800 Stansel Dr, Ruleville, MS 38771 · For profit - Limited Liability company · 111 certified beds · (662) 756-4361 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Aug 2025Resident-funds citation (F0565)Behavioral-health or dementia-care citation — no harm found (F0758)4 immediate-jeopardy citations$101,474 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — 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 cited 4 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $101,474 in federal fines (most recent 2025-08-28)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 1 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

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
840 N Oak Ave · (601) 354-4488 · Call to confirm hours
Pharmacy
Grocery
650 N Oak Ave · (662) 756-2825 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
801 Stansel Dr · (662) 756-0085

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

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased22.3%20.5%15.4%worse
Long-stay residents who lose too much weight7.6%6.2%5.4%worse
Long-stay residents with a catheter left in their bladder0.7%1.4%0.9%better
Long-stay residents with a urinary tract infection0.2%2.5%2.0%better
Long-stay residents with depressive symptoms0.0%1.6%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury3.1%3.1%3.3%typical
Long-stay residents whose ability to walk worsened22.4%19.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication42.7%23.8%18.9%worse
Long-stay residents given the seasonal flu vaccine97.3%97.0%95.3%typical
Long-stay residents with pressure ulcers4.6%6.3%4.7%typical
Long-stay residents with worsening bladder/bowel control13.0%20.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table63.9%21.7%17.1%check this — see note marked dagger below the table
Short-stay residents rehospitalized after admission32.4%27.7%22.6%worse
Short-stay residents with an outpatient ER visit13.6%15.5%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.252.431.67worse
Long-stay outpatient ER visits per 1,000 resident days3.752.861.80worse

* 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.

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. 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.

12.0%U.S. median 10.7%
Went back to hospital
0.13U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.03hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.0%CMS range 7.4–17.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified87.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay8.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened16.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.7%CMS range 4.0–13.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.391.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.46
RN hours/ resident / day
1.04
LPN hours/ resident / day
2.44
Aide hours/ resident / day
3.94
Total nurse hours/ resident / day
0.27
RN hoursweekends
52.9%
Total nursing turnover
58.3%
RN turnover

How full it usually is: this home is certified for 111 beds and averages 98.6 residents a day — about 89% occupied, or roughly 12 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 3.94 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.44 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 3.23 hrs/resident/day on weekends vs 4.22 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.54 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

10
deficiencies at the latest standard inspection (2025-08-27)
10
at the previous standard inspection (2023-11-30)

Deficiencies are unchanged from the previous inspection. 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.

ABCDEFGHIJKL

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

29 citations, most serious first. The 15 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-05-31 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 staff interviews, record review, and facility policy review the facility failed to protect one (1) of 108 residents right to be free from neglect as evidenced by [DATE] Resident #3 being unwilling to sleep in his room with his roommate due to Resident #1 getting in the bed with Resident #3. This resulted in the death of another resident (Resident #2) when Resident #1 laid on top of Resident #2 who was placed in the room with Resident #1. The facility's neglect to identify roommate incompatibility and provide appropriate person-centered behavioral interventions from [DATE]-[DATE] placed Resident #2 at risk, caused his death and placed other residents in a situation which was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE], which began on [DATE], when the facility neglected to ensure appropriate services for residents with behavioral needs. The facility's failure to provide appropriate…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2024-05-31 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 staff interview, care plan review, record review, and facility policy review, the facility failed to revise a comprehensive care plan related to behaviors for (1) one of 13 residents reviewed for care plans. Resident #1 The facility's failure to revise Resident #1's care plans with appropriate interventions related to his known behavior of getting into bed with other residents resulted in staff not having access to preventative measures to deter this behavior. On [DATE], Resident #1 was found in bed on top of Resident #2 with only his hands visible beneath Resident #1. Resident #2 was unresponsive and did not respond to life sustaining measures and was pronounced dead. This placed the residents residing in the facility at risk, and in a situation that was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) on [DATE], which began on [DATE] when the facility failed to revise Resident #1's behavior care plan. On [DATE] at 10:30 AM, the SA…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2024-05-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and facility policy review, the facility failed to provide adequate supervision to reduce the risk of an accident/hazards when a resident with behaviors got into other resident's beds and did not have any increased supervision/monitoring put in place resulting, in the physical assault and death of a resident for (1) one of (4) four residents reviewed for accidents. (Resident #2) The facility's failure to provide adequate supervision and monitoring, placed Resident #2 and other residents residing in the facility at risk, and in a situation which caused Resident #2's death and was likely to cause serious injury, serious harm, serious impairment, or death for others. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE], which began on [DATE], when the facility failed to provide increased supervision/monitoring and ensure appropriate services for residents with behavioral needs. The facility's failure to provide…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2024-05-31 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and facility policy review, the facility failed to recognize behaviors and provide appropriate person-centered behavioral interventions for one (1) of three (3) residents with documented behaviors resulting in the physical assault and death of a resident. (Resident #1) The facility's failure to identify behaviors and failure to provide appropriate person-centered behavioral interventions and supervision, from [DATE] through [DATE] resulted in the death of Resident #2 and placed other residents at risk, and in a situation which was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE], which began on [DATE], when the facility failed to identify behaviors, and ensure appropriate services for residents with behavioral needs. The facility's failure to identify potential abuse, failure to provide appropriate person-centered behavioral interventions and supervision…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-08-27 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident received treatment and services to manage pain as evidenced by the facility failing to administer fentanyl patches as ordered for one (1) of five (5) medication reviews (Resident #106). This failure resulted in missed doses of prescribed pain medication and escalating pain levels causing actual harm through unnecessary suffering. Resident #106Findings Include: Review of the facility policy titled Pain Evaluation/Management reviewed 8/25 revealed under, Policy: All residents will be evaluated for pain at the time of administration, readmission, quarterly and as needed.An interview on 8/25/2025 at 10:55 AM with Resident #106 revealed he hurt in 26 different areas of his body and had chronic pain every day. He explained he had been using fentanyl patches for about 19 months and took gabapentin and oxycodone twice daily to help manage his pain. The resident further reported he also used lidocaine patches, bio freeze, and Tylenol as needed. He explained that a nurse…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-27 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement a care plan for resident's dependent on staff for nail care (Resident #6, #16, #102), showers (Resident #88, #94) and pain management (Resident #106) for six (6) of 31 sampled residents. Resident #6, #16, #88, #94, #102, #106 Findings Include: Review of the facility policy titled Comprehensive Person-Centered Care Plans unrevised, revealed, Policy: Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Resident #6 Record review of the Care plans for Resident #6 revealed under, Goals: I will maintain my current level of ADL (activities of daily living) status. Also revealed under, Interventions: extensive assist of one for personal hygiene. On 8/25/2025 at 11:12 AM, during an observation and interview with Resident #6, he held out his right hand and stated, I have claws, and voiced that he needed his nails trimmed. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-27 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide 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, resident and staff interviews, record review, and facility policy review, the facility failed to provide basic hygiene care by not ensuring that a dependent resident received showers (Resident #88 and Resident #94) and routine nail care (Resident #6, Resident #16, and Resident #102) for five (5) of eight (8) residents reviewed for activities of daily living (ADLs). Findings Include Review of the facility policy titled Fingernails/Toenails Care unrevised, revealed, Policy: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. Record review of undated facility policy, Bath/Shower-Dependent revealed, A bath (shower/tub) for cleanliness and comfort is scheduled at least weekly for each resident. Resident #6 An observation and interview with Resident #6 on 8/25/2025 at 11:12 AM in the resident's room, he held out his right hand and stated, I have claws, and voiced that he needed his nails trimmed. He explained he had been trying to get someone to help him for a couple of days. The resident's nails were long,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-27 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents' rights to reasonable accommodation of needs by not providing access to oral hydration for two (2) of ninety-six residents reviewed (Resident #38 and Resident #47).Findings IncludeTop of Form Record review of the facility policy titled, Resident [NAME] of Rights undated, revealed, Each resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the Facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life . 10. Reside and receive services in the facility with reasonable accommodation of resident needs. Resident #38 Observation and interview on 8/25/2025 at 10:25 AM, revealed Resident #38 sitting in her room. No water was observed in either a water pitcher or a cup. The resident stated, I'll have to go up the hall to get some water. An…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-27 · tag F0565 — failed to support the resident council — isolated
    Honor 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 staff and resident interview, record review and facility policy review, the facility failed to resolve a grievance for one (1) of eight (8) residents present at the resident council meeting. (Anonymous Resident).Findings IncludeReview of the facility policy titled Grievance/Missing Property with a revision date of 8/17 revealed under Purpose .to provide an opportunity for residents, resident representatives and/or family to present concerns or grievance to the proper authorities at the facility and to receive responses to the issue(s) raised. Under Procedure .A.3 .Supervisory personnel shall be responsible for notifying the resident of resolution and so indicate on grievance form .An interview on 8/25/25 at 10:15 AM, Anonymous Resident complained that Certified Nursing Assistant (CNA) #6 jerked his legs when she turned him and it hurt his back. He admitted that he reported this to the staff, but no one had come to ask him about it.An interview and record review on 8/25/25 at 4:00 PM with the Director of Nurses (DON) confirmed that the Anonymous Resident had complained about…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-27 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review, the facility failed to maintain a safe, clean, and comfortable environment as evidenced by a bathroom floor covering that had been removed, leaving bare concrete with a black stained area around the toilet for one (1) of 38 residents on sample. Resident #43 Findings Include: Review of a typed statement on facility letterhead revealed the facility did not have a policy regarding maintenance repairs and was signed by the Administrator. On 8/25/25 at 9:05 AM, an observation revealed Resident #43's bathroom floor covering was removed. The floor was bare concrete with a black substance around the toilet base. During an observation and interview with the Housekeeper #1 on 8/26/25 at 11:06 AM, he stated he mopped the area, but the concrete floor could not be cleaned properly and that it had been that way for some time. On 8/26/25 at 11:30 AM, an interview with the Maintenance Staff #2, revealed that when flooring is torn or damaged, linoleum is sometimes removed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-27 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 resident and staff interviews, record reviews and facility policy review the facility failed to protect a resident's right to be free from verbal abuse for one (1) of five (5) residents reviewed for Abuse and Neglect. Resident #3 Findings IncludeTop of Form Top of Form Top of Form Review of the facility policy titled: Abuse Prevention undated, revealed, The facility is committed to protecting the residents from abuse by anyone, including, but not necessarily limited to: facility staff.Definitions: b) Verbal Abuse: The use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents . Review of the facility policy titled: Resident [NAME] of Rights, with a revision date of 1/23, revealed A. Facility residents shall have the right to: 36 . be free of abuse, neglect, exploitation, misappropriation of resident property . A record review of a written statement dated 2/14/25 and signed by Certified Nurse Aide (CNA) #1 revealed, I, (proper name 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-27 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 ensure that all alleged abuse violations were reported to the State Survey Agency as required. This deficient practice had the potential to place residents at risk for abuse and/or neglect. For three (3) of the five (5) alleged abuse violations reviewed. Resident #3, Anonymous Resident, and Resident #68. Findings Include Review of the facility policy titled: “Abuse Prevention” dated 10/22, revealed, “The facility is committed to protecting the residents from abuse by anyone, including, but not necessarily limited to: facility staff… under Reporting: Alleged violations involving abuse, neglect, …are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-27 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    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, record review and facility policy review the facility failed to investigate allegations of abuse for two (2) of five (5) residents reviewed for abuse. Residents #68 and Anonymous Resident Findings IncludeReview of the facility policy titled, with a revision date of 10/22 revealed under Investigate: .the facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation.An interview on 8/25/25 at 10:15AM with an Anonymous Resident revealed that Certified Nurse Assistant (CNA) #6 and CNA #7 came in to turn him and they jerked his legs and hurt his back. He admitted that he reported it to staff that he thought it was CNA #6 and admits that she hasn't worked with him since. He then stated that he reported to the Administrator that CNA #2 was giving him a bed bath and when he ask her to wash his back, she wet 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review and facility policy review the facility failed to provide restorative nursing services for residents with contractures for two (2) of 31 sampled residents. Resident #16 and Resident #94. Findings Include: Review of the facility policy, Range of Motion revealed that A range of motion program will be developed for a resident as indicated Purposes of ROM (Range of Motion) 1. Maintain or improve joint and soft tissue mobility. 2 Minimize contractures RESIDENT #16 An observation and interview on 08/25/25 at 2:45 PM with Resident #16, revealed her sitting in her wheelchair in the dining room. She had a contracture to her left wrist/hand and there was no orthotic device in use. An observation on 08/26/25 at 8:38 AM revealed Resident #16 lying in bed in her room. She had contracture to her left wrist/hand, and she had no orthotic device in place. She revealed that they sometimes rolled a towel and put it in her hand, but she couldn't remember the last time they applied it. Record review of Resident #16's Occupational Therapy Discharge Summary…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-27 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident and staff interviews, record review, and facility policy review, the facility failed to maintain accurate medical records for one (1) of five (5) medication reviews. Resident #106Findings include: Review of the facility policy titled Medication Administration -General Guidelines revised 8/16 revealed under, Policy: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Also revealed under, Procedure: . 9 . This individual records the administration on the resident's MAR/eMAR (medication administration record) and TAR/eTAR (treatment administration record) after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/TAR to ascertain that all necessary doses were administered and all administered doses were documented . During an interview with Resident #106 on 8/25/2025 at 10:55 AM, he revealed he had a problem with a nurse on 3-11 shift not applying his fentanyl patch and stated he was not getting it like he…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2024-06-25 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure 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, staff interview, record review, and facility policy review the facility failed to prevent a resident from being physically restrained with a sheet tied to the wheelchair. The facility also failed to obtain physician orders, consent and failed to assess a resident for the need of restraints (mattress with elevated sides and wedges) for one (1) of six (6) residents reviewed. Resident #1. Findings included: Review of the facility policy titled, Restraint Evaluation & (and) Restraint Reduction, revised 12/23, revealed, Policy: as per OBRA (Omnibus Budget Reconciliation Act) requirements, all residents have the right to be unrestrained. Restraints should be used only as a last alternative and only when other less restrictive measures have been tried and rejected.Definition: Physical Restraints are defined as any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access.Procedure: 2.) All residents using a restraint…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-25 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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 report an allegation of mistreatment when a resident was physically restrained with a sheet tied to the wheelchair for one (1) of six (6) residents reviewed. Resident #1. Findings Included: Review of the facility policy titled, Abuse Prevention, revealed the definition of mistreatment means inappropriate treatment of a resident. All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than two hours after the allegation is made. Record review of the facility occurrence, completed by the Director of Nursing (DON) revealed that an investigation was conducted on 6/10/24, when the DON was informed of a resident possibly having a sheet tied on her wheelchair the previous day. After staff interview which revealed four (4) Certified Nursing Assistants (CNAs) stated they saw the resident restrained on 6/9/24 with a sheet tied around the wheelchair, the facility determined that because the resident was recently combative and sliding down 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-11-30 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure 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, interview, policy review, and record review, the facility failed to ensure controlled medications were stored in a secure locked container for two (2) of six (6) narcotic storage containers. Findings Include: Review of the facility policy, Medication Storage revealed, Medication supply must be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy. Observation on 11/28/23 11:03 AM, of the [NAME] Wing Nurses Station medication room revealed a medication refrigerator with a red lock box for controlled drugs. The medication box was not locked but was secured to the refrigerator shelf. The box contained 12 single dose vials of Lorazapam and one (1) multidose vial of Lorazapam. The observation was confirmed by Licensed Practical Nurse (LPN ) #3 and LPN #4. Neither LPN had a key to lock the box. LPN #3 said the box is never locked but confirmed the medications are…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-30 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, record review, and facility policy review, the facility failed to maintain clean ice machines, as evidenced by observations during the annual survey of two (2) of two (2) unclean ice machines, for 96 of 105 residents in the nursing facility who use ice. Findings Include: Review of the facility policy titled, Ice Handling and Cleaning, for the Guideline and Procedure Manual . 2020, revealed Guideline: Ice will be stored and served to residents in a sanitary manner. Procedure: . 6. Ice machine will be emptied at least quarterly and thoroughly cleaned with an approved sanitizer to remove any settlement or mineral build-up . An observation on 11/28/23 at 10:35 AM, of the ice machine in the kitchen, revealed a black buildup that was located on the upper right side of the opening of the ice container under the door to the ice storage bin. An observation and interview on 11/28/23 at 10:38 AM, with the Kitchen Aide #2, revealed her use of a wet white paper towel to wipe over the black buildup that was located on the upper right side of the opening 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-30 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor 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 and interview, the facility failed to maintain a dining experience that promotes dignity as evidenced by staff standing while providing feeding assistance to one (1) of three (3) residents who required feeding assistance in the dining room. Resident #38. Findings Include: An observation of the lunch meal service in the west dining room for Resident #38 on 11/28/23 at 12:48 PM, revealed that the resident was sitting in his wheelchair at the table and Certified Nursing Assistant (CNA) #2 was standing beside the resident feeding him lunch. Upon interview with CNA #2 on 11/28/23 at 12:50 PM, she stated that she should not be standing while feeding Resident #38. She stated that she should be sitting at eye level while feeding so the resident does not feel intimidated with staff standing over him. CNA #2 stated that she only stands when there are not enough chairs in the dining area to sit in. An observation of the breakfast meal service in the west dining area for Resident # 38 on 11/29/23 at…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-30 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and facility policy review, the facility failed to submit a change in status referral for a Level II Pre-admission Screen and Resident Review (PASRR) resident review related to a new Mental Disorder (MD) diagnosis for one (1) of six (6) residents reviewed. Resident # 75. Findings include: Review of the facility's policy titled PASRR (Pre-admission Screen and Resident Review) Screening for Mental Disorder or Intellectual Disability, dated 9/23, revealed, Policy: Each resident in the nursing facility is screened for Mental Disorder (MD) as defined or Intellectual Disability (ID) prior to admission and that individuals identified with MD or ID are evaluated by the State mental health authority and receive care with services appropriate to their need. Referring all Level II with new MD, ID, or related conditions, a review upon a significant change in status assessment. RESPONSIBILITY: Social Services Department under the supervision of the Executive Director . Record review 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-30 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 complete a Pre-admission Screening and Resident Review (PASRR) for a resident with an identified Mental Disorder for one (1) of five (5) residents reviewed. Resident # 101. Findings include: A review of the facility policy titled, PASRR (Preadmission Screening and Resident Review) Screening for Mental Disorder or Intellectual Disability with a history date of 9/23, revealed, .Procedure: .3. A positive Level I screen necessitates an in-depth evaluation of the individual, by the state-designated authority, known as a Level II PASRR which must be conducted prior to admission to the facility . A record review of the Level 1 Preadmission Screening (PAS) results for Resident #101, screening date 8/1/23 revealed, Disease Diagnoses: Hallucinations, unspecified . Referral Questions: Does Resident #101 have any history of mental illness? Yes . Does Resident #101 take, or have a history of taking psychotropic medications? Yes . Antipsychotic? Yes. Mood Stabilizers and antidepressants? Yes .Screening…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-30 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, record review, and facility policy review, the facility failed to implement a care plan for changing behavior and side effect monitoring for a resident taking anticoagulants and psychotropic medications (Resident # 56) and failed to fully develop and implement a care plan for a Gastrostomy Tube (Resident #88) for (2) two of 23 residents reviewed for care plans. Findings include: Review of the facility policy titled, Comprehensive Person Centered Care Plans, with a history date of 3/18 revealed, POLICY: Each resident will have person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care . Resident #56 Review of the care plan for Resident #56 Problem Onset: 08/03/2023 I am at risk for complications related to using antidepressant medication for depressive disorder and psychotropic med (medication) for dx (diagnosis) of dementia with unspecified severity . Approaches: .Monitor for changes in mood/behavior/cognition, hallucinations, delusions, social 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and record review, the facility failed to prevent the potential for an accident by not utilizing appropriate staff when transferring a resident for one (1) of five (5) residents reviewed. Resident #90 Findings include: An observation on 11/28/23 at 10:26 AM revealed Nursing Assistant (NA) #1 had Resident #90 in a total body lift and had stopped the transfer of Resident #90 with the resident lifted approximately one (1) foot above the bed. NA #1 left the resident suspended over the bed and walked to doorway and stepped into the hallway looking down the hallway for other staff to assist her in transfer the resident. An interview, on 11/29/23 at 02:32 PM with the Director of Nurses (DON) revealed that she was very rattled over this, mainly because of resident safety. She stated that the facility has trained and done in-service education on this. The DON stated that they had plenty of CNA's working yesterday that could have helped her. At no point should this have…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-30 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure 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, interview and record review, the facility failed to ensure a resident with a gastrostomy tube received care to prevent complications as evidenced by failure to check tube placement prior to medication administration for Resident #88; for one of five care observations. Findings Include: Review of the facility policy titled, Tube Feeding, with a revision date of July 2018, revealed the policy/procedure failed to address the checking of residual with a gastrostomy tube (G tube) when administering medications. Record review of the November 2023 Physician Orders for Resident #88 revealed an order dated 1/18/23, CHECK PLACEMENT OF G TUBE VIA RESIDUAL. CHECK HOLD IF RESIDUAL IS > 100 CC . Record review of the Electronic Medication Administration Record (eMAR) for Resident #88 revealed CHECK PLACEMENT OF G Tube VIA RESIDUAL, dated 1/18/23. Observation on 11/29/23 at 8:40 AM, revealed Licensed Practical Nurse (LPN) #1 failed to check placement of the G tube prior to administering medications and flushing the tube. In an interview on 11/29/23 at 8:55 AM, LPN #1 revealed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-30 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, record review and facility policy review the facility failed to ensure a resident was monitored for medication side effects for the use of an anticoagulant medication for one (1) of three (3) residents reviewed. Resident # 56 Findings include: A review of the facility policy titled, Medication Monitoring revealed, .General Guidelines: 1. The staff and Physician shall strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication . A review of the Physician's Orders List for Resident #56 revealed an order dated 2/9/23 for Xarelto 2.5 mg (milligrams) tablet give one tablet by mouth twice a day with meals. A review of the November 2023 electronic Medication Administration Record (eMAR) for Resident # 56 revealed no monitoring for the use of the anticoagulant Xarelto. An interview with the Director of Nursing (DON) on 11/29/23 at 4:40 PM revealed she was unable to find any documentation for monitoring for side effects of the use 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, record and policy review the facility failed to ensure a resident received behavioral interventions or side effect monitoring with the use of psychotropic medications for one (1) of three (3) residents reviewed. Resident # 56 Findings include: A review of the facility policy titled, Medication Monitoring revealed, .General Guidelines: 1. The staff and Physician shall strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication . A review of the November 2023 electronic Medication Administration Record (eMAR) revealed Resident #56 receives Cymbalta 30 mg (milligrams) one capsule daily for depressive features, Zoloft 25 mg tablet daily, and Abilify 5 mg ½ (one half) tablet daily. No monitoring for behaviors or side effects were observed on the eMAR for the psychotropic medications. An interview with the Director of Nursing (DON) on 11/29/23 at 4:40 PM, revealed she was unable to find documentation for monitoring targeted…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 record review, staff and resident interview and facility policy review the facility failed to ensure a resident was free from abuse when a Certified Nursing Assistant (CNA) threw water on a resident for one (1) of six (6) residents reviewed for abuse. Resident # 1. Findings include: A record review of the facility policy titled, Abuse Prevention, with a revision date of 10/22, revealed Policy: The facility is committed to protecting the residents from abuse by anyone including but not necessarily limited to: facility staff .or any other individual . A record review of the facility Supervisor Investigation Summary Report Form revealed that on August 24, 2023, the Director of Nursing (DON) reported to the Administrator that Registered Nurse (RN) #1 had reported to her an employee-to-resident abuse altercation between Resident # 1 and CNA #1. RN #1 noticed Resident #1's shirt was wet and noticed water on the floor. Resident #1 stated that CNA #1 poured a cup of ice-cold water on her due to CNA #1 stating…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview and resident interview the facility failed to provide a safe and clean homelike environment as evidenced by dirty floors and loose metal corner molding in resident rooms for two (2) of 64 rooms observed. Findings include: An interview, on 7/14/22 at 2:28 PM, with the Administrator confirmed the facility does not have a policy regarding building repair. An observation of room E 20 on 7/11/22 at 4:30 PM, revealed the corner of the wall by the bathroom door had metal molding approximately 2 feet long and 2 inches wide that was disconnected from the wall and would swing when touched. This observation revealed that behind the loose corner molding was a hole in the sheetrock with crumbling sheetrock, which resulted in sheetrock dust and approximately 4 pieces of 1 inch by 1 inch sheetrock in the floor beneath the hole. An observation on 7/13/22 at 10:00 AM, revealed the corner by the bathroom with the loose corner molding and crumbling sheetrock had not been repaired. An observation and interview on 7/14/22 at 2:15 PM, with the Administrator 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$101,474 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $22,315 — penalty dated 2025-08-28
  • $79,159 — penalty dated 2024-05-31
  • Medicare payment denial — starting 2024-06-27 for 23 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.6M
Net patient revenuemost recent cost report
-4.8%
Operating marginrevenue minus expenses
$1.6M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 84%Medicare 12%Other / private 4%

About 84% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$261per resident / day
operating cost
$7,948per month
≈ monthly operating cost
$249per day
avg. revenue, all payers

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

What families pay in MS

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 255113. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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