Cycle 1
Health 2025-08-28 · Fire 2025-08-28
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Hattiesburg, MS
Bedford Care Ctr-Monroe Hall
4-star overall rating with 5-star inspections with 2 recent health deficiencies
300 Cahal Street, Hattiesburg, MS
(601) 582-9157
Overall
4 / 5
CMS overall stars
Health inspections
5 / 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
80
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bedford Care Centers
Operator or chain grouping
Approved since
2003-05-01
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
0.69
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.66
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
4.37
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.71
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
4.80
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,037
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9848
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.51
Baseline 22.84% · Performance 20.51% · Measure score 3.51 · Achievement 1.99 · Improvement 3.51
Healthcare-associated infections
0
Baseline 9.28% · Performance 11.04% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.09
Baseline 66.67% · Performance 60.00% · Measure score 1.09 · Achievement 0.9 · Improvement 1.09
Adjusted total nurse staffing
6.60
Baseline 4.22 hours · Performance 4.96 hours · Measure score 6.60 · Achievement 6.60 · Improvement 4.22
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.24% |
10.72%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 20.59% · Lower 95% interval 9.62% |
| Discharge to community | 42.83% |
50.57%
7.7 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 35.14% · Lower 95% interval 30.93% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.88% |
95.27%
1.6 pts better
|
Numerator 31 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 11 · Denominator 22 |
| Discharge mobility score | 45.45% |
50.94%
5.5 pts worse
|
Numerator 10 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 1 · Denominator 32 · Adjusted rate 2.7% |
| Healthcare-associated infections requiring hospitalization | 11.04% |
7.12%
3.9 pts worse
|
No Different than the National Rate · Eligible stays 40 · Observed rate 25% · Lower 95% interval 6.27% |
| Staff COVID-19 vaccination coverage | 8.77% |
8.2%
0.6 pts better
|
Numerator 10 · Denominator 114 |
| Staff flu vaccination coverage | 25% |
42%
17 pts worse
|
Numerator 30 · Denominator 120 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 11 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · 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 | 2.7 |
2.4
0.3 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
2.9
0.2 pts better
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
95.7%
1.5 pts worse
|
93.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 92.3% · Q3 93.8% · Q4 95.5% · 4Q avg 94.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.0%
3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.2%
0.5 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 3.1% · Q4 4.5% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.3% |
1.6%
12.7 pts worse
|
11.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 12.7% · Q3 9.3% · Q4 17.9% · 4Q avg 14.3% |
| Percentage of long-stay residents who lose too much weight | 11.0% |
6.1%
4.9 pts worse
|
5.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 19.7% · Q3 3.2% · Q4 15.4% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.2% |
24.4%
5.8 pts worse
|
19.6%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 29.5% · Q3 30.2% · Q4 33.8% · 4Q avg 30.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.8% |
23.4%
3.6 pts better
|
16.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 19.6% · Q3 20.4% · Q4 16.3% · 4Q avg 19.8% · 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 | 20.9% |
22.8%
1.9 pts better
|
16.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.4% |
20.6%
0.2 pts better
|
14.9%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 15.4% · Q3 26.4% · Q4 20.0% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.5%
0.1 pts better
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.0% · Q3 1.0% · Q4 1.3% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.8% |
2.5%
3.3 pts worse
|
1.7%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.6% · Q3 9.4% · Q4 4.5% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.9% |
21.4%
6.5 pts better
|
19.8%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 10.3% · Q3 22.8% · Q4 6.3% · 4Q avg 14.9% |
| Percentage of long-stay residents with pressure ulcers | 9.1% |
6.9%
2.2 pts worse
|
5.1%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 13.5% · Q3 7.1% · Q4 9.0% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.7% |
87.9%
4.2 pts worse
|
81.7%
2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.6% · Q2 78.0% · Q3 88.0% · Q4 84.2% · 4Q avg 83.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.4% |
15.3%
5.1 pts worse
|
12.0%
8.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.4% · Observed 25.5% · Expected 14.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
2.6%
0.5 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 7.1% · Q3 0.0% · Q4 2.3% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.0% |
84.6%
9.4 pts better
|
79.7%
14.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.3% |
27.9%
5.6 pts better
|
23.9%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 27.7% · Expected 29.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-28 · Fire 2024-03-28
5 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.
Cycle 3
Health 2022-02-18 · Fire 2022-02-18
4 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-22
D · Potential for more than minimal harm
2025-08-28
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 2025-09-22
D · Potential for more than minimal harm
2024-10-29
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 2024-11-19
D · Potential for more than minimal harm
2024-10-29
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 2024-11-19
D · Potential for more than minimal harm
2024-10-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-03-28
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-19
D · Potential for more than minimal harm
2022-02-18
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 2022-04-08
D · Potential for more than minimal harm
2022-02-18
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-04-08
D · Potential for more than minimal harm
2022-02-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-04-08
D · Potential for more than minimal harm
2022-02-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-08
Penalties and ownership
What sits behind the stars
Ownership
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 Indirect Ownership Interest · Individual
Bevon, Nicole
Corporate Director · Individual
Bevon, Nicole
Corporate Officer · Individual
Casada, Daniel
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
Forrest General Hospital Skilled Nursing Unit
Hattiesburg, MS
5-star overall rating with 5-star inspections with 1 recent health deficiencies
#3
Bedford Care Center Of Hattiesburg
Hattiesburg, MS
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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