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
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
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
Staffing
RN hours / resident day
0.58
Registered nurse staffing
LPN hours / resident day
1.03
Licensed practical nurse staffing
Aide hours / resident day
2.23
Nurse aide staffing
Weekend hours
3.45
Weekend nurse staffing
RN turnover
67%
Annual RN turnover
Total nurse turnover
66%
Annual nurse turnover
Quality measures
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Resident Rights (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-12
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-21
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
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
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-21
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-10
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
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-12
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-12
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-10-12
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
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-12
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
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-12
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-12
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
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-10-12
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2023-10-12
Health
Post nurse staffing information every day.
Corrected 2023-10-12
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-31
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-05-31
Penalties and ownership
Fine · fine $30,602
Fine
Payment Denial · denial start 2024-08-30 · 11 days
11 day denial
Fine · fine $4,376
Fine
Fine · fine $4,376
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Mortgage Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
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