Cycle 1
Health 2025-02-27 · Fire 2025-02-27
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Ashland, MS
Ashland Health And Rehabilitation
5-star overall rating with 4-star inspections with 4 recent health deficiencies
16056 Boundry Drive, Ashland, MS
(662) 224-6196
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vanguard Healthcare
Operator or chain grouping
Approved since
1991-06-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.86
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.58
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
4.47
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.89
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.70
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.07
CMS adjusted RN staffing hours
Adjusted total hours
5.57
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,308
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9858
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.43
Baseline 18.34% · Performance 20.31% · Measure score 2.43 · Achievement 2.43 · Improvement 0
Healthcare-associated infections
0
Baseline 5.73% · Performance 7.74% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.23
Baseline 54.55% · Performance 42.31% · Measure score 5.23 · Achievement 5.23 · Improvement 3.62
Adjusted total nurse staffing
4.39
Baseline 4.24 hours · Performance 4.33 hours · Measure score 4.39 · Achievement 4.39 · Improvement 0.08
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.37% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 9.09% · Lower 95% interval 7.07% |
| Discharge to community | 45.99% |
50.57%
4.6 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 34.55% · Lower 95% interval 34.26% |
| Medicare spending per beneficiary | 1.45 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 96.72% |
95.27%
1.5 pts better
|
Numerator 59 · Denominator 61 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 61 |
| Discharge self-care score | 75% |
53.69%
21.3 pts better
|
Numerator 33 · Denominator 44 |
| Discharge mobility score | 63.64% |
50.94%
12.7 pts better
|
Numerator 28 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 3.28% |
2.29%
1 pts worse
|
Numerator 2 · Denominator 61 · Adjusted rate 3.78% |
| Healthcare-associated infections requiring hospitalization | 7.74% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 9.62% · Lower 95% interval 4.33% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 96 |
| Staff flu vaccination coverage | 51.52% |
42%
9.5 pts better
|
Numerator 51 · Denominator 99 |
| Discharge function score | 65.91% |
56.45%
9.5 pts better
|
Numerator 29 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.65% |
96.28%
0.6 pts worse
|
Numerator 22 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 11 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.4
0.3 pts better
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.9
0.7 pts better
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.0%
3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.2%
0.8 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.9% · Q3 1.8% · Q4 3.9% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.6%
1.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
6.1%
5.5 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.3% |
24.4%
1.9 pts worse
|
19.6%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.6% · Q2 27.7% · Q3 20.4% · Q4 25.0% · 4Q avg 26.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.4% |
23.4%
8 pts better
|
16.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 16.7% · Q3 16.7% · Q4 13.5% · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.3% |
22.8%
6.5 pts better
|
16.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 16.9% · Q3 15.5% · Q4 7.4% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.4% |
20.6%
8.2 pts better
|
14.9%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 8.7% · Q3 10.2% · Q4 11.4% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.5%
1.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.5%
2.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.1% |
21.4%
3.3 pts better
|
19.8%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 28.9% · Q3 13.9% · Q4 8.6% · 4Q avg 18.1% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
6.9%
2.1 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 4.1% · Q3 0.0% · Q4 3.6% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
87.9%
7.9 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 90.9% · Q4 89.7% · 4Q avg 95.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.2% |
15.3%
4.9 pts worse
|
12.0%
8.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 20.4% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.6%
2.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
84.6%
9.7 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
27.9%
4.1 pts better
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 20.4% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-21 · Fire 2023-11-21
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-17 · Fire 2022-08-17
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-02-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-02-27
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-03-25
F · Potential for more than minimal harm
2023-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-21
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-21
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-15
Penalties and ownership
What sits behind the stars
Ownership
Vanguard Healthcare, LLC
5% Or Greater Direct Ownership Interest · Organization
Ervin General Partnership
5% Or Greater Indirect Ownership Interest · Organization
Fick, John
Corporate Officer · Individual
Jere Suzanne Ervin Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
North Mississippi Management Associates, LLC
Operational/Managerial Control · Organization
Orand LP
5% Or Greater Indirect Ownership Interest · Organization
Orand, William
5% Or Greater Indirect Ownership Interest · Individual
Orand, William
Corporate Director · Individual
Orand, William
Corporate Officer · Individual
Stacks, Denise
W-2 Managing Employee · Individual
William Jeffrey Ervin Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Holly Springs Rehabilitation And Healthcare Center
Holly Springs, MS
1-star overall rating with 2-star inspections with $8,278 in total fines with 10 recent health deficiencies
#2
Diversicare Of Ripley
Ripley, MS
1-star overall rating with 1-star inspections with $72,793 in total fines with 10 recent health deficiencies
#3
Rest Haven Health And Rehabilitation
Ripley, MS
2-star overall rating with 2-star inspections with 8 recent health deficiencies
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