Tupelo Community Care Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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.

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.

45.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 133 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 57.7% 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 97 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 0.35 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% 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.

Staffing

How full it usually is: this home is certified for 120 beds and averages 108.4 residents a day — about 90% 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 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.72 hrs/resident/day on weekends vs 3.62 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.51 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are 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.

35 citations, most serious first. The 15 most serious are shown; the remaining 20 are one tap away and print in full.

• Immediate jeopardy · J2023-08-09 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  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 reviews, and facility policy review, the facility failed to implement the baseline plan of care for Res #1 who was a high risk for elopement, and had displayed exit seeking behaviors. Res #1 was one (1) of five (5) residents reviewed. The facility failed to provide supervision as outlined in the baseline care plan for hourly visual checks to prevent an elopement for Res #1, who was diagnosed with Dementia. Res #1 was allowed to leave the facility, unnoticed and unsupervised until the local Law Enforcement found the resident 4.2 miles away from the facility. During the investigation the State Agency (SA) identified an Immediate Jeopardy (IJ). The IJ had existed on 08/02/23 when Res #1 eloped from the facility unsupervised. The SA notified the facility's Administrator of the IJ on 08/08/23 at 10:10 AM and provide the IJ Template. The elopement placed Res #1 and other residents at risk for wandering and elopement, at risk for the likelihood of serious injury, harm, impairment, or…

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

  Resident Assessment and Care Planning Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2023-08-09 · 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 staff interviews, record review and facility policy review the facility failed to provide supervision to prevent a resident from leaving the facility unsupervised for one (1) of five (5) residents reviewed, Resident #1. The facility failed to provide supervision to prevent the elopement of Res #1 who was an elopement risk and had an order for visual checks every hour. Resident #1 was diagnosed with Dementia with Psychotic Disturbance. He was last seen by staff at approximately 12:20 PM on 08/02/23. He was allowed to leave the facility, unnoticed and unsupervised. Res #1 walked approximately 4.2 miles away from the facility in 94 degree weather along a busy highway before he was found by the local law enforcement at approximately 3:00 PM. The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that existed on 08/02/23 when Res #1 eloped from the facility unsupervised. The SA notified the facility's Administrator (ADM) on 08/08/23 at 10:15 AM and provided the IJ template. The…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2025-12-11 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review and facility policy review, the facility failed to implement a fall care plan for Resident # 3 and failed to implement a fluid restriction care plan for Resident #87 for two (2) of 23 care plans reviewed. Findings Include: Review of a facility policy titled, Goals and Objectives, Care Plans, last revised September 2013, revealed the policy statement indicated that care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. An observation conducted on 12/10/25 at 8:30 AM revealed Resident #3 in bed with three-quarter length side rails raised on both sides of the bed. Record review of a care plan titled, I am at high risk for falls related to impaired mobility and unawareness of safety precautions, initiated 9/5/24 and last revised 2/28/25, revealed interventions included use of three-quarter length side rails as enablers to assist with turning and repositioning while in bed, with…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-12-11 · 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 interviews, and record review, the facility failed to ensure adequate accident prevention for one (1) of five (5) residents reviewed for accident hazards (Resident #3). The facility failed to ensure the resident's ordered three-quarter length side rail was maintained in the raised position while the resident was in bed, resulting in the resident rolling out of bed and sustaining a fracture. Findings Include:Review of a statement on facility letterhead revealed that Proper Name Care Center did not have a specific policy pertaining to accident prevention.An observation conducted on 12/10/25 at 8:30 AM revealed Resident #3 in bed with three-quarter length side rails raised on both sides of the bed.Review of the Medication Review Report dated 1/13/25 revealed an order for three-quarter length side rails to be used as enablers to assist with turning and repositioning while in bed, with instructions to release and reposition every two hours and as needed.Review of an accident…

  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 · G2025-02-18 · 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 reviews, resident and staff interviews, facility policy review, the facility failed to ensure a resident's right to be free from abuse and reprisal by staff. Resident #1 was verbally abused and confronted by Licensed Practical Nurse (LPN #1) for reporting that she had not received pain medications in a time when Resident #1 asked for them. Resident #1 was one (1) of three (3) residents reviewed for abuse and neglect. Findings include: The facility undated policy titled Abuse Prevention revealed, The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff . a) Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a care taker of goods or services are necessary to attain or maintain physical, mental and psychosocial well-being. b) Verbal abuse: The use of oral, written, or…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-06-10 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff and resident interviews, record review and facility policy review, the facility failed to ensure a call light was maintained within reach for a resident who was dependent for assistance for 3 (three) of 6 (six) residents reviewed. Resident #1, Resident #2 and Resident #5. Findings Include: Review of the facility policy Call Light/Call Pager Systems with effective date of 09/09/22 revealed, .The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room . An observation and interview on 06/10/26 at 9:55 AM revealed Resident #1 lying in bed in his room. He revealed that he had been having trouble with his call light, but he now had a clip attached to the call light cord and he kept it clipped to his clothes. He revealed that prior to having the clip, he had to call his family three or four different times because his call light was on the floor or in the trash can and he couldn't reach it. He revealed that he was not able to get up without help and if he could not reach his call light, he had…

  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 · D2025-12-11 · 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

  Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure resident privacy was maintained during medication administration for a resident with a gastrostomy tube for one (1) of six (6) care opportunities observed. Resident #16Findings Include: Review of the facility policy titled Dignity with a revision date of 2/21 revealed under, Policy Interpretation and Implementation: . 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. An observation during medication pass on 12/10/2025 at 8:15 AM with Licensed Practical Nurse (LPN) #3 revealed she administered medications to Resident #16 via a gastrostomy tube while the room blind was half open, allowing the resident to be visible from the back parking lot and compromising the resident's bodily privacy. An interview with LPN #3 on 12/10/25 at 8:32 AM confirmed the window blind was left open while administering medications to Resident #16 and revealed this was a privacy concern for 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 Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-11 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, record review, and facility policy review, each resident had the right to determine their end-of-life care and the facility failed to ensure the desired code status of the resident was reflected in the documentation for one (1) of 23 sample residents reviewed. Resident #10Findings include: Record review of the facility policy titled, Advance Directives, undated, revealed, It is the policy of the facility to respect the resident's right of self-directed care including the right to issue Advance Directives on health care, to refuse or accept treatment, to make informed decisions, and/or appoint a health care agent to make decision on the behalf of the resident when the resident lacks the capacity to do so. 1. Each competent adult has the right to control his or her own health care decisions. Record review of facility policy titled, Resident Rights dated [DATE], revealed, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights…

  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 before2025-12-11 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, staff interview, and facility policy review, the facility failed to accurately complete section K of the Minimum Data Set (MDS) for one (1) of 23 minimum data sets reviewed. Resident #100.Findings Include: Review of the facility policy titled Certifying Accuracy of the Resident Assessment undated, revealed under, Policy Statement: All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. Record review of the Weights and Vitals Summary for Resident #100 revealed the following documented weights: 10/08/25 252 pounds10/28/25 252 pounds11/03/25 249.6 pounds11/13/25 230.8 pounds11/18/25 230.7 pounds Record review revealed Resident #100 has a significant weight loss of 21 pounds and -8.3% (percent) in 1 month. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/25 revealed under section K0300, Resident #100 did not have a weight loss of 5 % (percent) or more in the last month, which was inaccurate. An interview with the MDS Nurse on 12/11/25…

  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 · D2025-12-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide 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 observation, record review, staff interview, and facility policy review, the facility failed to ensure fluid intake was managed, tracked, and documented in accordance with a physician ordered fluid restriction for a resident receiving dialysis for one (1) of six (6) resident reviewed for fluid restrictions. Resident #87Findings Include:Review of the facility policy titled Encouraging and Restricting Fluids revised 10/10 revealed under, Purpose: The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. The policy further revealed under, Steps in the Procedure: . 5. Record the amount of fluid consumed on the intake side of the intake and output record. Record fluid in MLs (milliliters).Record review of Resident #87's December 2025 Medication Administration Record (MAR) revealed an order dated 7/16/25, Record fluid intake in 24 hours. 900 cc (cubic centimeter) fluid restriction - Breakfast 200, Lunch 200, Dinner 200, Medications 200, Snacks 100. Review revealed there was no documentation of fluid intake amounts…

  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 · D2025-12-11 · tag F0808 — failed to follow doctor-ordered diets — isolated
  Ensure 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, resident and staff interview, and record review, the facility failed to ensure meals were served in accordance with a resident's physician-ordered nutritional requirements for one (1) of four (4) residents reviewed for dining. Resident #87Findings Include:The facility provided a statement on letterhead that read, (Proper name of the facility) does not have a specific policy on therapeutic diet.During an observation on 12/09/25 at 8:06 AM, Resident #87 was observed sitting up in her wheelchair in her room with her breakfast tray in front of her untouched. The resident had 2 pieces of bacon, scrambled eggs, toast, water, and apple juice. Review of the meal ticket dated 12/09/25 revealed, Supplements: Nepro - 1 carton and under Notes; Add Nepro to all trays. The Nepro supplement was not on the meal tray. Resident #87 stated she only received it sometimes.An observation and interview with Licensed Practical Nurse (LPN) #1 on 12/09/25 at 8:12 AM confirmed Resident #87 did not receive the Nepro supplement as ordered on the meal ticket. LPN #1 stated the meal provided…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-11 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, staff interview, record review, and facility policy review, the facility failed to clean and disinfect a multi-use glucometer according to the manufacturer's instructions and the required wet contact time for one (1) of two (2) glucometers observed. Resident #16Findings Include: Review of the facility policy titled Assure Prism Multi Blood Glucose Monitor System: Use, Cleaning and Controls Policy undated, revealed under, Cleaning and Disinfecting the Assure Prism Multi Blood Glucose Monitoring System: 1. Follow standard precautions and the manufacture's disinfection procedures to clean and disinfect the meter. On 12/10/25 at 8:15 AM, an observation of Licensed Practical Nurse (LPN) #3 revealed she completed a blood glucose check for Resident #16 and then cleaned the glucometer using Sani-cloth germicidal wipes by swiping over the front and back of the machine three times for a total of 30 seconds. LPN #3 explained this was how she had been trained to clean the glucometer and stated this was the method their facility policy instructed them to use. LPN #3 was…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-09-11 · tag F0726 — failed to have competent, trained nursing staff — widespread
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview and record review, the facility failed to ensure that staff were trained on dementia care prior to caring for residents with dementia for one (1) of three (3) survey days. Findings Include: Record review of a typed statement on facility letterhead, dated September 11, 2024 and signed by the Executive Director revealed (Proper name of facility) do not have a policy on training staff or competency of staff. Record review of a typed statement on facility letterhead, dated September 11, 2024 and signed by the Executive Director revealed (Proper name of facility) have not implemented training on Dementia Care. An interview on 09/10/24 at 11:05 AM, with Certified Nurse Assistant (CNA) #1 and CNA #2 revealed they had been working at the facility for about 4 months and had not been trained on dementia care. CNA #1 stated that she did not know any special considerations regarding dealing with residents that have dementia and that she did not have any residents on her assigned B hall that had dementia. An interview on 09/10/24 at 11:48 AM, with the Staff Development…

  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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-09-11 · tag F0835 — failed to run the facility competently — widespread
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, staff and resident interviews and record reviews, the facility failed to be administered in a way that allows it to use its resources effectively to ensure the wellbeing of its residents for three (3) of three (3) days of survey. Findings Include: This tag is cross referenced to F561, F584, F677, F725, F726, F758, F908, F924 & F947. Record review of a typed statement on facility letterhead dated September 11, 2024, and signed by the Executive Director revealed (Proper name of facility) do not have a policy on Administration or Administrative Staff. We have a job description for each employee position. Record review of the facilities Job Description with an effective date of 8/01/12 revealed Job Title: Executive Director . General Description .The Executive Director leads and directs the overall operation of the Facility in accordance with resident needs .so as to maintain quality care for the residents .Essential Duties 1. Works with the Facility management staff in planning all aspects of Facility's operations, including setting priorities and job…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-09-11 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, staff and resident interviews, record review and facility policy review, the facilities Quality Assessment Performance Improvement (QAPI)/ Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee put into place. This failure resulted in four recited deficiencies that was originally cited on the 5/18/23 recertification survey. The recited deficiencies were in the areas of failing to implement an Activities of Daily Living (ADL) care plan, assist residents with ADL's, monitor for side effects of psychotropic medications and place an infectious resident in contact isolation. The continued failures during 2 recertification's shows a pattern of the facilities inability to sustain an effective Quality Assurance Program. Findings Include: This tag is cross referenced to: F656, F677, F758 and F880. Review of the facility policy titled, Quality Improvement Program with a revision date of 10/2022 revealed under the Policy .The Quality Improvement Committee will assess and monitor the quality…

  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.

  Administration 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.

Fines & penalties

$61,998 in federal fines across 5 penalties. 1 Medicare payment denial on record.

• $12,438 — penalty dated 2025-12-11
• $34,047 — penalty dated 2025-02-18
• $5,171 — penalty dated 2024-09-11
• $5,171 — penalty dated 2024-09-11
• $5,171 — penalty dated 2024-09-11
• Medicare payment denial — starting 2025-03-13 for 4 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

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

Follow the money — this home’s finances

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

About 72% 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 $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

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

What families pay in MS