Cycle 1
Health 2024-05-09 · Fire 2024-05-09
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Carthage, MS
Carthage Senior Care
4-star overall rating with 5-star inspections with 3 recent health deficiencies
302 Ellis Street, Carthage, MS
(601) 267-1352
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
58
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trend Consultants
Operator or chain grouping
Approved since
2021-06-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 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
0.60
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.81
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
1.49
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.40
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.19
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
0.75
CMS adjusted RN staffing hours
Adjusted total hours
5.40
CMS adjusted total nurse staffing hours
Case-mix index
1.09
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
40
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
94.10
Composite VBP score used to determine payment impact.
Payment multiplier
1.0275
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
8.82
Baseline 46.94% · Performance 27.63% · Measure score 8.82 · Achievement 8.82 · Improvement 8.24
Adjusted total nurse staffing
10
Baseline 5.05 hours · Performance 6.25 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.98% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 10.71% · Lower 95% interval 7.09% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.45 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 28 · Denominator 28 |
| Falls with major injury | 3.57% |
0.77%
2.8 pts worse
|
Numerator 1 · Denominator 28 |
| Discharge self-care score | 69.57% |
53.69%
15.9 pts better
|
Numerator 16 · Denominator 23 |
| Discharge mobility score | 60.87% |
50.94%
9.9 pts better
|
Numerator 14 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 7.14% |
2.29%
4.8 pts worse
|
Numerator 2 · Denominator 28 · Adjusted rate 7.46% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 7.21% |
8.2%
1 pts worse
|
Numerator 8 · Denominator 111 |
| Staff flu vaccination coverage | 58.97% |
42%
17 pts better
|
Numerator 69 · Denominator 117 |
| Discharge function score | 73.91% |
56.45%
17.5 pts better
|
Numerator 17 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · 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 | 2.9 |
2.4
0.5 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.1 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.9 |
2.9
3 pts worse
|
1.8
4.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.9 · Observed 4.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
95.7%
3 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.5% · Q4 98.2% · 4Q avg 98.7% |
| 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 | 3.9% |
3.2%
0.7 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.3% · Q3 3.5% · Q4 1.8% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.6%
1.6 pts better
|
11.4%
11.4 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 who lose too much weight | 0.5% |
6.1%
5.6 pts better
|
5.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.1% |
24.4%
6.7 pts worse
|
19.6%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 32.7% · Q3 29.4% · Q4 28.3% · 4Q avg 31.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.2% |
23.4%
8.2 pts better
|
16.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 18.0% · Q3 12.2% · Q4 9.8% · 4Q avg 15.2% · 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 | 20.5% |
22.8%
2.3 pts better
|
16.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.9% · Q2 31.2% · Q4 12.6% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.6% |
20.6%
11 pts worse
|
14.9%
16.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.9% · Q2 33.3% · Q3 19.1% · Q4 26.5% · 4Q avg 31.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
1.5%
0.7 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 4.1% · Q4 1.3% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.5%
0.2 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 0.0% · Q4 5.5% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.2% |
21.4%
2.2 pts better
|
19.8%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 26.6% · Q3 24.1% · Q4 9.9% · 4Q avg 19.2% |
| 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 6.9% · Q2 3.5% · Q3 4.9% · Q4 7.4% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.0% |
87.9%
7.9 pts worse
|
81.7%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 80.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.7% |
15.3%
4.4 pts worse
|
12.0%
7.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 20.0% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.5% |
27.9%
1.6 pts worse
|
23.9%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.5% · Observed 24.0% · Expected 19.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-27 · Fire 2023-04-27
1 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-06-24 · Fire 2021-06-24
0 health deficiencies
No concentrated health issue counts in this cycle.
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
2024-05-09
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 2024-06-01
D · Potential for more than minimal harm
2024-05-09
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 2024-06-01
D · Potential for more than minimal harm
2024-05-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-06-01
D · Potential for more than minimal harm
2023-04-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-25
Penalties and ownership
What sits behind the stars
Ownership
Kelly, Charles
5% Or Greater Direct Ownership Interest · Individual
Warnock, Lori
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Trend Health & Rehab Of Carthage LLC
Carthage, MS
2-star overall rating with 2-star inspections with $9,475 in total fines with 4 recent health deficiencies
#2
Attala County Nursing Center
Kosciusko, MS
2-star overall rating with 3-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Choctaw Residential Center
Choctaw, MS
2-star overall rating with 3-star inspections with $21,165 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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