Cycle 1
Health 2024-10-24 · Fire 2024-10-24
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Hattiesburg, MS
Bedford Care Center Of Hattiesburg
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
10 Medical Boulevard, Hattiesburg, MS
(601) 264-3709
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bedford Care Centers
Operator or chain grouping
Approved since
1992-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 3 overall / 3 health / 4 staffing / 2 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
0.37
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.30
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.18
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
1.67
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.45
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
4.14
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,802
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.86% · Performance 26.43% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.42% · Performance 8.47% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.41
Baseline 57.41% · Performance 53.85% · Measure score 2.41 · Achievement 2.41 · Improvement 0.59
Adjusted total nurse staffing
5.22
Baseline 4.29 hours · Performance 4.56 hours · Measure score 5.22 · Achievement 5.22 · Improvement 1.32
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.77% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 190 · Observed rate 15.79% · Lower 95% interval 9.96% |
| Discharge to community | 54.36% |
50.57%
3.8 pts better
|
No Different than the National Rate · Eligible stays 153 · Observed rate 47.06% · Lower 95% interval 46.18% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 7.34% |
95.27%
87.9 pts worse
|
Numerator 8 · Denominator 109 |
| Falls with major injury | 0.92% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 109 |
| Discharge self-care score | 36.99% |
53.69%
16.7 pts worse
|
Numerator 27 · Denominator 73 |
| Discharge mobility score | 28.77% |
50.94%
22.2 pts worse
|
Numerator 21 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 0.92% |
2.29%
1.4 pts better
|
Numerator 1 · Denominator 109 · Adjusted rate 0.87% |
| Healthcare-associated infections requiring hospitalization | 8.47% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 111 · Observed rate 9.91% · Lower 95% interval 5.23% |
| Staff COVID-19 vaccination coverage | 2.65% |
8.2%
5.5 pts worse
|
Numerator 4 · Denominator 151 |
| Staff flu vaccination coverage | 32.03% |
42%
10 pts worse
|
Numerator 49 · Denominator 153 |
| Discharge function score | 35.62% |
56.45%
20.8 pts worse
|
Numerator 26 · Denominator 73 |
| Transfer of health information to provider | 37.84% |
95.95%
58.1 pts worse
|
Numerator 14 · Denominator 37 |
| Transfer of health information to patient | 97.92% |
96.28%
1.6 pts better
|
Numerator 47 · Denominator 48 |
| Resident COVID-19 vaccinations up to date | 29.79% |
25.2%
4.6 pts better
|
Numerator 14 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.4
0.5 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.7 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.9
0.4 pts better
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.5 · 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 | 98.7% |
97.0%
1.7 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.2%
1.8 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 1.5% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.6% |
1.6%
1 pts worse
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.1% · Q3 3.1% · Q4 2.9% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 13.3% |
6.1%
7.2 pts worse
|
5.4%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 21.9% · Q3 6.8% · Q4 10.6% · 4Q avg 13.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.2% |
24.4%
10.2 pts better
|
19.6%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 10.6% · Q3 15.0% · Q4 16.7% · 4Q avg 14.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.6% |
23.4%
7.8 pts better
|
16.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 15.7% · Q3 19.6% · Q4 17.3% · 4Q avg 15.6% · 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 | 30.4% |
22.8%
7.6 pts worse
|
16.3%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.6% |
20.6%
3 pts better
|
14.9%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 24.1% · Q3 20.0% · Q4 14.0% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.1% |
1.5%
1.6 pts worse
|
1.0%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.4% · Q3 4.2% · Q4 4.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
2.5%
1.1 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.4% · Q3 1.5% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.4% |
21.4%
9 pts worse
|
19.8%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 29.9% · Q3 20.1% · Q4 38.9% · 4Q avg 30.4% |
| Percentage of long-stay residents with pressure ulcers | 8.8% |
6.9%
1.9 pts worse
|
5.1%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 8.9% · Q3 6.1% · Q4 7.9% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
87.9%
11.3 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 98.9% · Q3 99.0% · Q4 100.0% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
15.3%
7.1 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 9.5% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
2.6%
1 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 0.0% · Q4 3.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.0% |
84.6%
4.4 pts better
|
79.7%
9.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
27.9%
2.1 pts better
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 31.6% · Expected 29.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-16 · Fire 2023-02-16
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-09-26 · Fire 2019-09-26
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-24
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 2024-11-21
D · Potential for more than minimal harm
2024-10-24
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-21
E · Potential for more than minimal harm
2023-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-16
C · Minimal harm
2023-02-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-03-16
E · Potential for more than minimal harm
2019-09-26
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-25
Penalties and ownership
What sits behind the stars
Ownership
Bedford Health Properties, LLC
5% Or Greater Direct Ownership Interest · Organization
Bevon, Charles
Operational/Managerial Control · Individual
Bevon, Jack
Corporate Director · Individual
Bevon, Jack
Corporate Officer · Individual
Bevon, Nicole
5% Or Greater Indirect Ownership Interest · Individual
Bevon, Nicole
Corporate Director · Individual
Bevon, Nicole
Corporate Officer · Individual
Fairchild, Lisa
Operational/Managerial Control · Individual
Hattiesburg Medical Park Management Corp.
Operational/Managerial Control · Organization
Janet F Mcelroy Family Trust Fbo Nicole Mcelroy Bevon
5% Or Greater Indirect Ownership Interest · Organization
Janet F. Mcelroy Family Trust Fbo Michael E. Mcelroy, Jr.
5% Or Greater Indirect Ownership Interest · Organization
Mcelroy, Michael
5% Or Greater Indirect Ownership Interest · Individual
Mcelroy, Michael
Corporate Director · Individual
Mcelroy, Michael
Corporate Officer · Individual
Mcelroy, Sonya
Corporate Director · Individual
Mcelroy, Sonya
Corporate Officer · Individual
Michael E Mcelroy Family Trust Fbo Nicole Mcelroy Bevon
5% Or Greater Indirect Ownership Interest · Organization
Michael E. Mcelroy Family Trust Fbo Michael E. Mcelroy, Jr.
5% Or Greater Indirect Ownership Interest · Organization
Worrell, Stephen
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Bedford Alzheimer's Care Center
Hattiesburg, MS
4-star overall rating with 4-star inspections with $66,700 in total fines
#2
Bedford Care Ctr-Monroe Hall
Hattiesburg, MS
4-star overall rating with 5-star inspections with 2 recent health deficiencies
#3
Merit Health Wesley
Hattiesburg, MS
5-star overall rating with 4-star inspections with 2 recent health deficiencies
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