Cycle 1
Health 2025-03-06 · Fire 2025-03-06
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Choctaw, MS
Choctaw Residential Center
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
135 Residential Center Rd, Choctaw, MS
(601) 656-2582
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
109
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2013-08-25
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
0.42
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.12
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
0.51
CMS adjusted RN staffing hours
Adjusted total hours
4.50
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,667
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.1
Baseline 19.63% · Performance 20.92% · Measure score 1.1 · Achievement 1.1 · Improvement 0
Healthcare-associated infections
0.90
Baseline 7.78% · Performance 7.56% · Measure score 0.90 · Achievement 0.90 · Improvement 0.26
Total nurse turnover
0
Baseline 51.96% · Performance 85.84% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.82
Baseline 4.22 hours · Performance 4.73 hours · Measure score 5.82 · Achievement 5.82 · Improvement 2.80
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.68% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 16.46% · Lower 95% interval 7.71% |
| Discharge to community | 47.88% |
50.57%
2.7 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 31.71% · Lower 95% interval 31.4% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 58.82% |
95.27%
36.4 pts worse
|
Numerator 30 · Denominator 51 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 51 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 21 · Denominator 33 |
| Discharge mobility score | 60.61% |
50.94%
9.7 pts better
|
Numerator 20 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 1.96% |
2.29%
0.3 pts better
|
Numerator 1 · Denominator 51 · Adjusted rate 1.92% |
| Healthcare-associated infections requiring hospitalization | 7.56% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 11.63% · Lower 95% interval 3.92% |
| Staff COVID-19 vaccination coverage | 0.87% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 115 |
| Staff flu vaccination coverage | 79.69% |
42%
37.7 pts better
|
Numerator 102 · Denominator 128 |
| Discharge function score | 57.58% |
56.45%
1.1 pts better
|
Numerator 19 · Denominator 33 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · 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 | 57.14% |
25.2%
31.9 pts better
|
Numerator 16 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
2.4
0.9 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
2.9
0.3 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 2.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
95.7%
0.4 pts better
|
93.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 94.0% · Q3 98.1% · Q4 98.1% · 4Q avg 96.1% |
| 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 | 6.4% |
3.2%
3.2 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 6.0% · Q3 8.7% · Q4 3.8% · 4Q avg 6.4% · 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 | 2.2% |
6.1%
3.9 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 3.3% · Q3 1.1% · Q4 3.4% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.7% |
24.4%
0.3 pts worse
|
19.6%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 25.0% · Q3 22.3% · Q4 22.3% · 4Q avg 24.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.4% |
23.4%
7 pts better
|
16.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 19.4% · Q3 16.9% · Q4 13.8% · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.7% |
0.2%
0.5 pts worse
|
0.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.1% |
22.8%
4.7 pts better
|
16.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 9.0% · Q3 28.1% · Q4 21.4% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.9% |
20.6%
0.7 pts better
|
14.9%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 23.0% · Q3 18.2% · Q4 17.6% · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.7% |
1.5%
1.2 pts worse
|
1.0%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.7% · Q3 3.1% · Q4 2.5% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
2.5%
1.8 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.0% · Q3 5.0% · Q4 5.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.6% |
21.4%
9.8 pts better
|
19.8%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 11.3% · Q3 12.6% · Q4 15.0% · 4Q avg 11.6% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
6.9%
About the same
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 10.6% · Q3 3.5% · Q4 5.6% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.6% |
87.9%
1.3 pts worse
|
81.7%
4.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 80.6% · Q2 90.0% · Q3 93.3% · Q4 80.5% · 4Q avg 86.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.0% |
15.3%
2.7 pts worse
|
12.0%
6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 22.2% · Expected 13.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
2.6%
1.2 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 4.8% · Q4 4.3% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.6% |
84.6%
13 pts better
|
79.7%
17.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 36.5% |
27.9%
8.6 pts worse
|
23.9%
12.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 36.5% · Observed 38.9% · Expected 25.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-24 · Fire 2023-08-24
9 health deficiencies
Top issue: Resident Rights (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-04-14 · Fire 2021-04-14
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-26
F · Potential for more than minimal harm
2023-08-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-05
F · Potential for more than minimal harm
2023-08-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-06
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-04-24
E · Potential for more than minimal harm
2025-03-06
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 2025-04-24
D · Potential for more than minimal harm
2025-03-06
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-03-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-03-06
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 2025-05-23
D · Potential for more than minimal harm
2025-03-06
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-04-24
D · Potential for more than minimal harm
2025-03-06
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 2025-04-24
D · Potential for more than minimal harm
2025-03-06
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-03-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-03-06
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 2025-05-23
D · Potential for more than minimal harm
2023-08-24
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 2023-10-05
D · Potential for more than minimal harm
2023-08-24
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 2023-10-05
D · Potential for more than minimal harm
2023-08-24
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-05
D · Potential for more than minimal harm
2023-08-24
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 2023-10-05
D · Potential for more than minimal harm
2023-08-24
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 2023-10-05
D · Potential for more than minimal harm
2023-08-24
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 2023-10-05
D · Potential for more than minimal harm
2023-08-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-10-05
C · Minimal harm
2023-08-24
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 2023-10-05
D · Potential for more than minimal harm
2021-04-14
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 2021-06-21
D · Potential for more than minimal harm
2021-04-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-21
Penalties and ownership
What sits behind the stars
$21,165
2025-03-06
Fine
Fine · fine $21,165
Fine
Ownership
Mississippi Band Of Choctaw Indians
5% Or Greater Direct Ownership Interest · Organization
Ben, Cyrus
Corporate Officer · Individual
Flake, Berta
W-2 Managing Employee · Individual
Hale, Shelley
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Neshoba County Nursing Home
Philadelphia, MS
2-star overall rating with 2-star inspections with 9 recent health deficiencies
#2
Hilltop Manor Health And Rehabilitation Center
Union, MS
4-star overall rating with 3-star inspections with 7 recent health deficiencies
#3
J G Alexander Nursing Center
Union, MS
1-star overall rating with 2-star inspections with $16,720 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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