Cycle 1
Health 2024-04-18 · Fire 2024-04-18
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Ackerman, MS
Choctaw Nursing And Rehabilitation Center
1-star overall rating with 2-star inspections with $12,472 in total fines with 10 recent health deficiencies
311 West Cherry Street, Ackerman, MS
(662) 285-3257
Overall
1 / 5
CMS overall stars
Health inspections
2 / 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
60
Certified beds
Average residents
50
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2018-10-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.51
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.16
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
4.08
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.29
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
4.90
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,668
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.39
Composite VBP score used to determine payment impact.
Payment multiplier
1.0021
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
5.30
Performance 42.00% · Measure score 5.30 · Achievement 5.30 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.37
Baseline 4.02 hours · Performance 4.32 hours · Measure score 4.37 · Achievement 4.37 · Improvement 1.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | 44.83% |
95.27%
50.4 pts worse
|
Numerator 13 · Denominator 29 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 29 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.45% |
2.29%
1.2 pts worse
|
Numerator 1 · Denominator 29 · Adjusted rate 3.18% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.26% |
8.2%
4.9 pts worse
|
Numerator 3 · Denominator 92 |
| Staff flu vaccination coverage | 36.96% |
42%
5 pts worse
|
Numerator 34 · Denominator 92 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| 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 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · 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 | 2.2 |
2.4
0.2 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.9
0.6 pts better
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.6 · 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 | 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 | 4.2% |
3.2%
1 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 6.4% · Q3 4.3% · Q4 4.1% · 4Q avg 4.2% · 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 | 3.5% |
6.1%
2.6 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 0.0% · Q3 7.3% · Q4 2.2% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.1% |
24.4%
1.3 pts better
|
19.6%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 23.3% · Q3 26.2% · Q4 22.2% · 4Q avg 23.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.6% |
23.4%
6.2 pts worse
|
16.7%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 24.2% · Q3 34.5% · Q4 28.1% · 4Q avg 29.6% · 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 | 16.7% |
22.8%
6.1 pts better
|
16.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
20.6%
0.1 pts worse
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 20.0% · Q3 15.6% · Q4 15.2% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.6% |
1.5%
1.1 pts worse
|
1.0%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.5% · Q3 2.7% · Q4 1.3% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
2.5%
0.7 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 0.0% · Q3 2.2% · Q4 4.1% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.6% |
21.4%
0.2 pts worse
|
19.8%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.3% · Q2 8.7% · Q3 19.8% · Q4 18.2% · 4Q avg 21.6% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
6.9%
1.1 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 4.9% · Q3 7.8% · Q4 9.1% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
87.9%
10 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 100.0% · Q3 100.0% · 4Q avg 97.9% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
2.6%
0.2 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.2% |
84.6%
11.6 pts better
|
79.7%
16.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-11 · Fire 2023-01-11
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2019-10-02 · Fire 2019-10-02
2 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-01-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-02-13
D · Potential for more than minimal harm
2019-10-02
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2019-10-25
Inspection history
Recent health citations
G · Actual harm
2025-03-18
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 2025-04-10
G · Actual harm
2025-03-18
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 2025-04-10
E · Potential for more than minimal harm
2024-04-18
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-18
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 2024-05-17
D · Potential for more than minimal harm
2024-04-18
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 2024-05-17
D · Potential for more than minimal harm
2024-04-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-18
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 2024-05-17
D · Potential for more than minimal harm
2024-04-18
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 2024-05-17
D · Potential for more than minimal harm
2024-04-18
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-06-14
D · Potential for more than minimal harm
2024-04-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-17
E · Potential for more than minimal harm
2023-01-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-13
D · Potential for more than minimal harm
2023-01-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-02-13
D · Potential for more than minimal harm
2023-01-11
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 2023-02-13
E · Potential for more than minimal harm
2019-10-02
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 2019-11-08
E · Potential for more than minimal harm
2019-10-02
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-11-08
Penalties and ownership
What sits behind the stars
$8,278
2025-03-18
Fine
Fine · fine $8,278
Fine
$4,194
2023-11-06
Fine
Fine · fine $4,194
Fine
Ownership
Choctaw Regional Medical Center
5% Or Greater Direct Ownership Interest · Organization
Marinelli, Steve
Corporate Director · Individual
Marinelli, Steve
Corporate Officer · Individual
Proctor, Tammy
W-2 Managing Employee · Individual
Trilogy Healthcare Solutions LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Louisville Healthcare LLC
Louisville, MS
3-star overall rating with 2-star inspections with $8,788 in total fines with 5 recent health deficiencies
#2
Winston County Nursing Home
Louisville, MS
4-star overall rating with 3-star inspections with $12,155 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Diversicare Of Eupora
Eupora, MS
2-star overall rating with 2-star inspections with 13 recent health deficiencies
Jump out