Cycle 1
Health 2025-03-06 · Fire 2025-03-06
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Wiggins, MS
Azalea Gardens Nursing Center
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
530 Hall St, Wiggins, MS
(601) 928-5281
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
61
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-05-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.72
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.30
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
4.26
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
28%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
967
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.56
Composite VBP score used to determine payment impact.
Payment multiplier
1.0166
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
8.53
Baseline 57.53% · Performance 28.81% · Measure score 8.53 · Achievement 8.53 · Improvement 8.29
Adjusted total nurse staffing
3.78
Baseline 3.75 hours · Performance 4.15 hours · Measure score 3.78 · Achievement 3.78 · Improvement 1.48
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.83% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 20.69% · Lower 95% interval 7.67% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 80% |
95.27%
15.3 pts worse
|
Numerator 16 · Denominator 20 |
| Falls with major injury | 5% |
0.77%
4.2 pts worse
|
Numerator 1 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 15% |
2.29%
12.7 pts worse
|
Numerator 3 · Denominator 20 · Adjusted rate 10.75% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.16% |
8.2%
7 pts worse
|
Numerator 1 · Denominator 86 |
| Staff flu vaccination coverage | 17.28% |
42%
24.7 pts worse
|
Numerator 14 · Denominator 81 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.4
1 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.9
1 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
95.7%
3 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.7% |
| 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 | 1.8% |
3.2%
1.4 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.8% · Q3 1.7% · Q4 1.7% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
1.6%
0.3 pts worse
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 3.6% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
6.1%
0.4 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.1% · Q3 6.2% · Q4 4.2% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.3% |
24.4%
6.9 pts worse
|
19.6%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 34.7% · Q3 32.0% · Q4 25.0% · 4Q avg 31.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.5% |
23.4%
2.1 pts worse
|
16.7%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 26.7% · Q3 27.5% · Q4 23.1% · 4Q avg 25.5% · 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 | 35.1% |
22.8%
12.3 pts worse
|
16.3%
18.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.2% |
20.6%
8.6 pts worse
|
14.9%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 30.8% · Q3 32.5% · Q4 26.8% · 4Q avg 29.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.5%
0.1 pts better
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 2.7% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 9.8% |
2.5%
7.3 pts worse
|
1.7%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 5.4% · Q3 8.9% · Q4 12.1% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
21.4%
0.6 pts worse
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 19.1% · Q3 16.9% · Q4 31.1% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
6.9%
2.7 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 3.4% · Q3 4.5% · Q4 3.7% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
87.9%
3.6 pts better
|
81.7%
9.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 95.2% · 4Q avg 91.5% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.6% |
2.6%
1 pts worse
|
1.6%
2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.0% |
84.6%
3.6 pts worse
|
79.7%
1.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-22 · Fire 2023-06-22
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-01-31 · Fire 2020-01-31
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-06
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-05-02
F · Potential for more than minimal harm
2025-03-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-02
D · Potential for more than minimal harm
2020-01-31
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2020-01-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-10
C · Minimal harm
2025-03-06
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-04-10
E · Potential for more than minimal harm
2023-06-22
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 2023-07-28
E · Potential for more than minimal harm
2023-06-22
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 2023-07-28
D · Potential for more than minimal harm
2023-03-02
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-03-24
J · Immediate jeopardy
2020-01-31
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2020-02-28
J · Immediate jeopardy
2020-01-31
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 2020-02-28
J · Immediate jeopardy
2020-01-31
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2020-02-28
J · Immediate jeopardy
2020-01-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-02-28
J · Immediate jeopardy
2020-01-31
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2020-02-28
G · Actual harm
2020-01-31
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2020-02-28
E · Potential for more than minimal harm
2020-01-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2020-02-28
Penalties and ownership
What sits behind the stars
Ownership
Cain, Avonna
5% Or Greater Direct Ownership Interest · Individual
Cain, Avonna
Limited Partnership Interest · Individual
Hatten, Michele
Operational/Managerial Control · Individual
Johns, Stephen
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Stone County Rehabilitation And Nursing Ctr Inc
Wiggins, MS
4-star overall rating with 4-star inspections with $8,190 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Lamar Healthcare & Rehabilitation Center
Lumberton, MS
1-star overall rating with 2-star inspections with $10,527 in total fines with 7 recent health deficiencies
#3
Pearl River Co Nursing Home
Poplarville, MS
5-star overall rating with 4-star inspections with 6 recent health deficiencies
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