Cycle 1
Health 2025-12-18 · Fire 2025-12-18
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Picayune, MS
Bedford Care Center Of Picayune
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $8,617 in total fines with 10 recent health deficiencies
2797 Cooper Road, Picayune, MS
(601) 799-1616
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
116
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bedford Care Centers
Operator or chain grouping
Approved since
2016-03-23
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
0.45
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.82
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
4.48
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,381
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9898
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.50
Baseline 18.76% · Performance 19.35% · Measure score 4.50 · Achievement 4.50 · Improvement 0
Healthcare-associated infections
0
Baseline 6.35% · Performance 8.74% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.67
Baseline 48.53% · Performance 48.70% · Measure score 3.67 · Achievement 3.67 · Improvement 0
Adjusted total nurse staffing
6.39
Baseline 4.41 hours · Performance 4.90 hours · Measure score 6.39 · Achievement 6.39 · Improvement 3.04
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.78% |
10.72%
3.1 pts worse
|
Worse than the National Rate · Eligible stays 156 · Observed rate 19.23% · Lower 95% interval 11.07% |
| Discharge to community | 56.37% |
50.57%
5.8 pts better
|
No Different than the National Rate · Eligible stays 110 · Observed rate 48.18% · Lower 95% interval 44.97% |
| Medicare spending per beneficiary | 1.37 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 105 · Denominator 105 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 105 |
| Discharge self-care score | 57.97% |
53.69%
4.3 pts better
|
Numerator 40 · Denominator 69 |
| Discharge mobility score | 37.68% |
50.94%
13.3 pts worse
|
Numerator 26 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 4.76% |
2.29%
2.5 pts worse
|
Numerator 5 · Denominator 105 · Adjusted rate 4.22% |
| Healthcare-associated infections requiring hospitalization | 8.74% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 101 · Observed rate 10.89% · Lower 95% interval 4.82% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 74 |
| Staff flu vaccination coverage | 18.82% |
42%
23.2 pts worse
|
Numerator 16 · Denominator 85 |
| Discharge function score | 44.93% |
56.45%
11.5 pts worse
|
Numerator 31 · Denominator 69 |
| Transfer of health information to provider | 96.77% |
95.95%
0.8 pts better
|
Numerator 60 · Denominator 62 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | 26.67% |
25.2%
1.5 pts better
|
Numerator 12 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.4
0.1 pts better
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.8 |
2.9
0.9 pts worse
|
1.8
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 3.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
95.7%
0.7 pts worse
|
93.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.1% · Q2 98.1% · Q3 94.2% · Q4 95.3% · 4Q avg 95.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
97.0%
0.4 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.2%
0.3 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.9% · Q3 4.8% · Q4 3.7% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.9% |
1.6%
5.3 pts worse
|
11.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 7.3% · Q3 6.3% · Q4 4.1% · 4Q avg 6.9% |
| Percentage of long-stay residents who lose too much weight | 11.1% |
6.1%
5 pts worse
|
5.4%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 12.0% · Q3 12.2% · Q4 12.2% · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.2% |
24.4%
7.8 pts worse
|
19.6%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 33.7% · Q3 34.4% · Q4 33.0% · 4Q avg 32.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.1% |
23.4%
6.7 pts worse
|
16.7%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 25.3% · Q3 31.9% · Q4 35.1% · 4Q avg 30.1% · 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 | 23.9% |
22.8%
1.1 pts worse
|
16.3%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 26.9% · Q3 15.9% · Q4 16.6% · 4Q avg 23.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.1% |
20.6%
1.5 pts worse
|
14.9%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 25.3% · Q3 24.1% · Q4 17.8% · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.5% |
1.5%
3 pts worse
|
1.0%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.1% · Q3 3.5% · Q4 3.1% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
2.5%
1 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 3.9% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.7% |
21.4%
3.3 pts worse
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 25.5% · Q3 23.3% · Q4 26.0% · 4Q avg 24.7% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
6.9%
1.6 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 6.1% · Q3 5.9% · Q4 4.9% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.7% |
87.9%
1.8 pts better
|
81.7%
8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.1% · Q2 94.5% · Q3 92.6% · Q4 86.6% · 4Q avg 89.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
15.3%
4.1 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 11.2% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
2.6%
0.6 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 4.4% · Q4 6.5% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.2% |
84.6%
3.6 pts better
|
79.7%
8.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.2% |
27.9%
4.7 pts better
|
23.9%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 21.3% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-23 · Fire 2024-05-23
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-08-18 · Fire 2022-08-18
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-05-23
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-07-22
E · Potential for more than minimal harm
2024-05-23
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-07-22
Inspection history
Recent health citations
J · Immediate jeopardy
2026-01-14
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 2026-02-02
J · Immediate jeopardy
2026-01-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-02-02
J · Immediate jeopardy
2026-01-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-02
J · Immediate jeopardy
2026-01-14
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 2026-02-02
J · Immediate jeopardy
2026-01-14
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2026-02-02
J · Immediate jeopardy
2026-01-14
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2026-02-02
E · Potential for more than minimal harm
2026-01-14
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 2026-02-02
D · Potential for more than minimal harm
2025-12-18
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-12-18
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 2026-01-21
D · Potential for more than minimal harm
2025-12-18
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 2026-01-21
F · Potential for more than minimal harm
2024-05-23
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 2024-07-10
E · Potential for more than minimal harm
2024-05-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-10
E · Potential for more than minimal harm
2024-05-23
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 2024-07-10
D · Potential for more than minimal harm
2024-05-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-05-23
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-05-23
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 2024-07-10
D · Potential for more than minimal harm
2024-05-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-10
G · Actual harm
2024-02-08
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 2023-11-03
G · Actual harm
2024-02-08
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 2023-11-03
G · Actual harm
2024-02-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-03
G · Actual harm
2024-02-08
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 2023-11-03
G · Actual harm
2024-02-08
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 2023-11-03
G · Actual harm
2024-02-08
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-11-03
D · Potential for more than minimal harm
2022-08-18
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-08-18
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 2022-10-14
Penalties and ownership
What sits behind the stars
$8,617
2024-02-08
Fine
Fine · fine $8,617
Fine
Ownership
Michael E Mcelroy Family Trust Fbo Nicole Mcelroy Bevon
5% Or Greater Indirect Ownership Interest · Organization
Worrell, Stephen
5% Or Greater Indirect Ownership Interest · Individual
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
Michael E. Mcelroy Family Trust Fbo Michael E. Mcelroy, Jr.
5% Or Greater Indirect Ownership Interest · Organization
Bedford Health Properties, LLC
5% Or Greater Direct Ownership Interest · Organization
Bevon, Jack
Corporate Director · Individual
Bevon, Jack
Corporate Officer · Individual
Bevon, Nicole
5% Or Greater Direct Ownership Interest · Individual
Hattiesburg Medical Park Management Corp.
Operational/Managerial Control · Organization
Mcelroy, Michael
5% Or Greater Direct Ownership Interest · Individual
Mcelroy, Michael
Operational/Managerial Control · Individual
Mcelroy, Sonya
Corporate Director · Individual
Mcelroy, Sonya
Corporate Officer · Individual
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#2
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Slidell, LA
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#3
Heritage Manor Of Slidell
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4-star overall rating with 4-star inspections with $11,333 in total fines with 4 recent health deficiencies
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