Cycle 1
Health 2025-02-06 · Fire 2025-02-06
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mendenhall, MS
Bedford Care Center Of Mendenhall
1-star overall rating with 1-star inspections with $39,354 in total fines with 5 recent health deficiencies
925 West Mangum Avenue, Mendenhall, MS
(601) 847-1311
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
56
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
0.58
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
2.23
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.84
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.61
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
0.41
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
4.29
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
66%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,265
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.31
Composite VBP score used to determine payment impact.
Payment multiplier
0.9845
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
0.80
Baseline 74.72% · Performance 68.25% · Measure score 0.80 · Achievement 0 · Improvement 0.80
Adjusted total nurse staffing
4.67
Baseline 3.81 hours · Performance 4.41 hours · Measure score 4.67 · Achievement 4.67 · Improvement 2.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.44% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 14.04% · Lower 95% interval 8.27% |
| Discharge to community | 39.33% |
50.57%
11.2 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 24.24% · Lower 95% interval 24.19% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 30 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | 41.67% |
53.69%
12 pts worse
|
Numerator 10 · Denominator 24 |
| Discharge mobility score | 8.33% |
50.94%
42.6 pts worse
|
Numerator 2 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 1 · Denominator 30 · Adjusted rate 4.06% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.35% |
8.2%
6.8 pts worse
|
Numerator 1 · Denominator 74 |
| Staff flu vaccination coverage | 38.55% |
42%
3.5 pts worse
|
Numerator 32 · Denominator 83 |
| Discharge function score | 25% |
56.45%
31.5 pts worse
|
Numerator 6 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · 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 | 4.3 |
2.4
1.9 pts worse
|
1.9
2.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.3 · Observed 4.5 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.4 |
2.9
2.5 pts worse
|
1.8
3.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.4 · Observed 5.8 · Expected 1.8 · 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 | 98.4% |
97.0%
1.4 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.1% |
3.2%
4.9 pts worse
|
3.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 5.3% · Q3 10.7% · Q4 9.1% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.4% |
1.6%
6.8 pts worse
|
11.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 8.5% · Q3 4.3% · Q4 10.9% · 4Q avg 8.4% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
6.1%
0.2 pts better
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.8% · Q3 5.8% · Q4 8.0% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.1% |
24.4%
4.7 pts worse
|
19.6%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 35.8% · Q3 32.7% · Q4 23.5% · 4Q avg 29.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.4% |
23.4%
1 pts worse
|
16.7%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 28.6% · Q3 25.6% · Q4 17.5% · 4Q avg 24.4% · 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 | 35.4% |
22.8%
12.6 pts worse
|
16.3%
19.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.5% |
20.6%
1.9 pts worse
|
14.9%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 14.6% · Q3 22.0% · Q4 31.2% · 4Q avg 22.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.5%
1.1 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
2.5%
2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.2% |
21.4%
6.8 pts worse
|
19.8%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 31.6% · Q3 30.4% · Q4 18.4% · 4Q avg 28.2% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
6.9%
1.2 pts better
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 6.6% · Q3 9.9% · Q4 4.3% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
87.9%
10.5 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · 4Q avg 98.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.0% |
15.3%
7.7 pts worse
|
12.0%
11 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 27.3% · Expected 13.2% · 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 rehospitalized after a nursing home admission | 35.6% |
27.9%
7.7 pts worse
|
23.9%
11.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.6% · Observed 31.8% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-07 · Fire 2023-09-07
14 health deficiencies
Top issue: Resident Rights (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-04-30 · Fire 2021-04-30
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.
Inspection history
Recent health citations
G · Actual harm
2025-12-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-12
E · Potential for more than minimal harm
2025-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-06
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-06
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 2025-03-21
D · Potential for more than minimal harm
2025-02-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-21
K · Immediate jeopardy
2024-08-05
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 2024-09-10
K · Immediate jeopardy
2024-08-05
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 2024-09-10
G · Actual harm
2024-08-05
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-09-10
G · Actual harm
2023-12-13
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 2023-11-12
G · Actual harm
2023-12-13
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 2023-11-12
D · Potential for more than minimal harm
2023-09-07
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-07
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-07
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-07
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-07
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 2023-10-12
C · Minimal harm
2023-09-07
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-10-12
C · Minimal harm
2023-09-07
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2023-10-12
C · Minimal harm
2023-09-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-12
E · Potential for more than minimal harm
2021-04-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-31
D · Potential for more than minimal harm
2021-04-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-05-31
Penalties and ownership
What sits behind the stars
$30,602
2024-08-05
Fine
Fine · fine $30,602
Fine
$0
2024-08-05
Payment Denial
Payment Denial · denial start 2024-08-30 · 11 days
11 day denial
$4,376
2023-12-13
Fine
Fine · fine $4,376
Fine
$4,376
2023-12-13
Fine
Fine · fine $4,376
Fine
Ownership
Bedford Health Properties, LLC
5% Or Greater Direct Ownership Interest · Organization
Bean, Lisa
Operational/Managerial Control · Individual
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
Blackledge, Richard
Operational/Managerial Control · Individual
Gibson, Rhonda
Operational/Managerial Control · Individual
Gilbert, Heather
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
Martin, Robert
Operational/Managerial Control · Individual
Mcelroy, Michael
5% Or Greater Indirect Ownership Interest · Individual
Mcelroy, Michael
Operational/Managerial Control · Individual
Mcelroy, Michael
Corporate Director · Individual
Mcelroy, Michael
Corporate Officer · 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
Trustmark National Bank
5% Or Greater Mortgage Interest · Organization
Worrell, Stephen
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
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Hillcrest Nursing Center
Magee, MS
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Briar Hill Rest Home
Florence, MS
2-star overall rating with 2-star inspections with abuse icon flag with $8,788 in total fines with 6 recent health deficiencies
#3
Ms Care Center Of Raleigh
Raleigh, MS
5-star overall rating with 4-star inspections with 1 recent health deficiencies
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