Cycle 1
Health 2024-07-11 · Fire 2024-07-11
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Marion, MS
Bedford Care Center Of Marion
1-star overall rating with 1-star inspections with $268,624 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
6434 A Dale Dr, Marion, MS
(601) 294-3515
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bedford Care Centers
Operator or chain grouping
Approved since
2009-09-01
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
0.50
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.28
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
4.30
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.68
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
4.35
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
78%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,295
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.16
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
0
Baseline 20.67% · Performance 21.85% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.73
Baseline 7.86% · Performance 5.83% · Measure score 6.73 · Achievement 6.73 · Improvement 6.60
Total nurse turnover
0
Baseline 64.60% · Performance 62.73% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.34
Baseline 3.95 hours · Performance 4.60 hours · Measure score 5.34 · Achievement 5.34 · Improvement 3.04
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.46% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 9.52% · Lower 95% interval 6.88% |
| Discharge to community | 27.99% |
50.57%
22.6 pts worse
|
Worse than the National Rate · Eligible stays 53 · Observed rate 16.98% · Lower 95% interval 18.63% |
| Medicare spending per beneficiary | 1.51 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 36.59% |
95.27%
58.7 pts worse
|
Numerator 15 · Denominator 41 |
| Falls with major injury | 4.88% |
0.77%
4.1 pts worse
|
Numerator 2 · Denominator 41 |
| Discharge self-care score | 56.52% |
53.69%
2.8 pts better
|
Numerator 13 · Denominator 23 |
| Discharge mobility score | 30.43% |
50.94%
20.5 pts worse
|
Numerator 7 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 9.76% |
2.29%
7.5 pts worse
|
Numerator 4 · Denominator 41 · Adjusted rate 6.97% |
| Healthcare-associated infections requiring hospitalization | 5.83% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 0% · Lower 95% interval 2.89% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 107 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 182 |
| Discharge function score | 34.78% |
56.45%
21.7 pts worse
|
Numerator 8 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · 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 18 · 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 | 3.9 |
2.4
1.5 pts worse
|
1.9
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 3.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.4 |
2.9
1.5 pts worse
|
1.8
2.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.4 · Observed 4.1 · 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 | 96.1% |
97.0%
0.9 pts worse
|
95.5%
0.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.8% |
3.2%
2.6 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.8% · Q3 6.3% · Q4 7.1% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.0% |
1.6%
13.4 pts worse
|
11.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 8.2% · Q3 14.8% · Q4 25.4% · 4Q avg 15.0% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
6.1%
1.3 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 3.2% · Q3 5.0% · Q4 4.6% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 43.8% |
24.4%
19.4 pts worse
|
19.6%
24.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.0% · Q2 41.5% · Q3 43.3% · Q4 43.3% · 4Q avg 43.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.7% |
23.4%
2.7 pts better
|
16.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 21.6% · Q3 21.3% · Q4 19.3% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 4.0% |
0.2%
3.8 pts worse
|
0.1%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 4.3% · Q3 4.8% · Q4 1.4% · 4Q avg 4.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 33.8% |
22.8%
11 pts worse
|
16.3%
17.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.9% · Q2 44.8% · Q4 11.1% · 4Q avg 33.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.5% |
20.6%
11.9 pts worse
|
14.9%
17.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.9% · Q2 32.8% · Q3 29.3% · Q4 25.8% · 4Q avg 32.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
1.5%
1.9 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 3.7% · Q3 1.9% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.9% |
2.5%
2.4 pts worse
|
1.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 3.0% · Q3 6.3% · Q4 2.9% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.3% |
21.4%
6.9 pts worse
|
19.8%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 30.1% · Q3 28.7% · Q4 29.3% · 4Q avg 28.3% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
6.9%
0.6 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 6.7% · Q3 6.2% · Q4 4.2% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
87.9%
12.1 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.9% |
15.3%
8.6 pts worse
|
12.0%
11.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 25.0% · Expected 11.7% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.6% |
84.6%
6 pts worse
|
79.7%
1.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 40.6% |
27.9%
12.7 pts worse
|
23.9%
16.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 40.6% · Observed 39.6% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-25 · Fire 2022-08-25
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-06-20 · Fire 2019-06-20
15 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
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
2024-07-11
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-07-25
Inspection history
Recent health citations
G · Actual harm
2024-11-25
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 2024-12-21
G · Actual harm
2024-11-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-21
E · Potential for more than minimal harm
2024-07-11
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-08-16
E · Potential for more than minimal harm
2024-07-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-11
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-11
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 2024-08-16
D · Potential for more than minimal harm
2024-07-11
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-11
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-01-30
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-29
J · Immediate jeopardy
2023-11-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-07
J · Immediate jeopardy
2023-11-16
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 2023-12-07
G · Actual harm
2023-10-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-11
G · Actual harm
2023-10-05
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 2023-11-11
J · Immediate jeopardy
2023-03-31
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 2023-05-01
J · Immediate jeopardy
2023-03-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-01
J · Immediate jeopardy
2023-03-31
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-05-01
E · Potential for more than minimal harm
2022-08-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-06
E · Potential for more than minimal harm
2022-08-25
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 2022-10-06
D · Potential for more than minimal harm
2022-08-25
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2022-10-06
D · Potential for more than minimal harm
2022-08-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-10-06
G · Actual harm
2019-06-20
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 2019-08-15
G · Actual harm
2019-06-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-08-15
E · Potential for more than minimal harm
2019-06-20
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 2019-08-15
D · Potential for more than minimal harm
2019-06-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-06-20
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-06-20
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-06-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-15
Penalties and ownership
What sits behind the stars
$6,370
2024-11-25
Fine
Fine · fine $6,370
Fine
$6,371
2024-11-25
Fine
Fine · fine $6,371
Fine
$232,114
2023-10-05
Fine
Fine · fine $232,114
Fine
$0
2023-10-05
Payment Denial
Payment Denial · denial start 2023-10-28 · 40 days
40 day denial
$7,923
2023-03-31
Fine
Fine · fine $7,923
Fine
$7,923
2023-03-31
Fine
Fine · fine $7,923
Fine
$7,923
2023-03-31
Fine
Fine · fine $7,923
Fine
Ownership
Bedford Health Properties, LLC
5% Or Greater Direct Ownership Interest · Organization
Estate Of Janet F. Mcelroy
5% Or Greater Indirect Ownership Interest · Organization
Mcelroy, Michael
5% Or Greater Indirect Ownership Interest · Individual
Worrell, Stephen
5% Or Greater Indirect Ownership Interest · Individual
Bevon, Charles
Operational/Managerial Control · Individual
Bevon, Jack
Corporate Director · Individual
Bevon, Nicole
5% Or Greater Direct Ownership Interest · Individual
Bevon, Nicole
Corporate Director · Individual
Bevon, Nicole
Corporate Officer · Individual
Mcelroy, Sonya
Corporate Director · Individual
Nearby options
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#2
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#3
The Oaks Rehabilitation And Healthcare Center
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1-star overall rating with 1-star inspections with abuse icon flag with $42,487 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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