Cycle 1
Health 2024-02-15 · Fire 2024-02-15
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cleveland, MS
Cleveland Community Care Center
1-star overall rating with 1-star inspections with $229,213 in total fines with 7 recent health deficiencies
4036 Highway 8 East, Cleveland, MS
(662) 843-4014
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Norbert Bennett & Donald Denz
Operator or chain grouping
Approved since
1989-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
29 facilities
Chain averages 2 overall / 2 health / 3 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
0.63
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.18
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.60
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.42
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
0.55
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
4.69
CMS adjusted total nurse staffing hours
Case-mix index
1.05
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,836
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9866
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.25
Baseline 22.87% · Performance 21.26% · Measure score 2.25 · Achievement 0 · Improvement 2.25
Healthcare-associated infections
0
Baseline 9.60% · Performance 11.54% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.13
Baseline 55.10% · Performance 42.72% · Measure score 5.13 · Achievement 5.13 · Improvement 3.59
Adjusted total nurse staffing
5.25
Baseline 3.51 hours · Performance 4.57 hours · Measure score 5.25 · Achievement 5.25 · Improvement 4.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.09% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 6.19% · Lower 95% interval 6.41% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| 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 52 · Denominator 52 |
| Falls with major injury | 1.92% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 52 |
| Discharge self-care score | 55.56% |
53.69%
1.9 pts better
|
Numerator 15 · Denominator 27 |
| Discharge mobility score | 48.15% |
50.94%
2.8 pts worse
|
Numerator 13 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 1.92% |
2.29%
0.4 pts better
|
Numerator 1 · Denominator 52 · Adjusted rate 1.67% |
| Healthcare-associated infections requiring hospitalization | 11.54% |
7.12%
4.4 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 15.71% · Lower 95% interval 6.79% |
| Staff COVID-19 vaccination coverage | 0.97% |
8.2%
7.2 pts worse
|
Numerator 1 · Denominator 103 |
| Staff flu vaccination coverage | 13.89% |
42%
28.1 pts worse
|
Numerator 20 · Denominator 144 |
| Discharge function score | 51.85% |
56.45%
4.6 pts worse
|
Numerator 14 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 38.1% |
25.2%
12.9 pts better
|
Numerator 8 · Denominator 21 |
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 3.3 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
2.9
About the same
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.7 · Expected 2.1 · 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 | 98.2% |
97.0%
1.2 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
3.2%
2.7 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · 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 | 5.2% |
6.1%
0.9 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 5.9% · Q3 4.9% · Q4 3.0% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.7% |
24.4%
15.3 pts worse
|
19.6%
20.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.0% · Q2 40.8% · Q3 37.9% · Q4 36.9% · 4Q avg 39.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 43.9% |
23.4%
20.5 pts worse
|
16.7%
27.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 34.5% · Q3 44.6% · Q4 46.3% · 4Q avg 43.9% · 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 | 12.0% |
22.8%
10.8 pts better
|
16.3%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 13.0% · Q3 21.0% · Q4 9.4% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.2% |
20.6%
2.4 pts better
|
14.9%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 11.0% · Q3 26.1% · Q4 18.1% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.5%
About the same
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.9% · Q3 1.6% · Q4 0.8% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.5%
2.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.2% |
21.4%
7.2 pts better
|
19.8%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 9.8% · Q3 21.9% · Q4 14.9% · 4Q avg 14.2% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
6.9%
3 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 1.6% · Q3 2.8% · Q4 5.3% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
87.9%
6.8 pts better
|
81.7%
13 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.5% · Q2 90.6% · Q3 94.3% · Q4 100.0% · 4Q avg 94.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.4% |
15.3%
9.1 pts worse
|
12.0%
12.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 29.2% · Expected 13.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.2% |
2.6%
1.6 pts worse
|
1.6%
2.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.2% |
84.6%
6.6 pts better
|
79.7%
11.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.5% |
27.9%
7.6 pts worse
|
23.9%
11.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.5% · Observed 31.2% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-29 · Fire 2022-06-29
1 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2019-06-06 · Fire 2019-06-06
11 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.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-06-29
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-08-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
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 2026-02-13
D · Potential for more than minimal harm
2026-01-08
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 2026-02-13
E · Potential for more than minimal harm
2024-02-15
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 2024-03-20
D · Potential for more than minimal harm
2024-02-15
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 2024-03-20
D · Potential for more than minimal harm
2024-02-15
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-15
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 2024-03-20
D · Potential for more than minimal harm
2024-02-15
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 2024-03-20
J · Immediate jeopardy
2023-09-11
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 2023-10-11
J · Immediate jeopardy
2023-09-11
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 2023-10-11
J · Immediate jeopardy
2023-09-11
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 2023-10-11
J · Immediate jeopardy
2023-09-11
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-10-11
J · Immediate jeopardy
2023-09-11
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-10-11
J · Immediate jeopardy
2023-09-11
F841 · Nursing and Physician Services Deficiencies
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2023-10-11
J · Immediate jeopardy
2023-09-11
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-06-15
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 2023-07-25
E · Potential for more than minimal harm
2022-06-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-11
D · Potential for more than minimal harm
2019-06-06
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-07-01
D · Potential for more than minimal harm
2019-06-06
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 2019-07-01
D · Potential for more than minimal harm
2019-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-07-01
Penalties and ownership
What sits behind the stars
$229,213
2023-09-11
Fine
Fine · fine $229,213
Fine
$0
2023-09-11
Payment Denial
Payment Denial · denial start 2023-10-07 · 4 days
4 day denial
Ownership
D&N, LLC
5% Or Greater Direct Ownership Interest · Organization
Dtd Hc, LLC
5% Or Greater Direct Ownership Interest · Organization
Bennett, Norbert
5% Or Greater Indirect Ownership Interest · Individual
Conrad, Kathy
W-2 Managing Employee · Individual
Denz, Donald
5% Or Greater Indirect Ownership Interest · Individual
Donald T Denz Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Norbert A Bennett Irrv Tr Fbo Children
5% Or Greater Indirect Ownership Interest · Organization
Norbert A Bennett Irrv Tr Fbo Grandchildren
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Bolivar Medical Center Ltc
Cleveland, MS
3-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Delta Rehabilitation And Healthcare Center
Cleveland, MS
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Walter B Crook Nursing Facility
Ruleville, MS
3-star overall rating with 3-star inspections with 7 recent health deficiencies
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