Cycle 1
Health 2025-01-16 · Fire 2025-01-16
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Brandon, MS
Community Place
3-star overall rating with 3-star inspections with 10 recent health deficiencies
116 Lake Vista Place, Brandon, MS
(601) 355-0617
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
57
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.75
Registered nurse staffing
LPN hours / resident day
1.54
Licensed practical nurse staffing
Aide hours / resident day
3.03
Nurse aide staffing
Weekend hours
3.68
Weekend nurse staffing
RN turnover
53%
Annual RN turnover
Total nurse turnover
63%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.4
0.7 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.9
1.6 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
95.7%
1.5 pts better
|
93.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.2%
1.3 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 1.1% |
6.1%
5 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
24.4%
6.4 pts better
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 23.6% |
23.4%
0.2 pts worse
|
16.7%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.9% |
0.2%
0.7 pts worse
|
0.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.7% |
22.8%
0.1 pts better
|
16.3%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.5% |
20.6%
0.1 pts better
|
14.9%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.5%
0.4 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
2.5%
0.6 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
21.4%
4.6 pts worse
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 10.4% |
6.9%
3.5 pts worse
|
5.1%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
87.9%
10.8 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
15.3%
7 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
2.6%
0.4 pts better
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.6% |
27.9%
12.3 pts better
|
23.9%
8.3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-17 · Fire 2023-08-17
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.
Cycle 3
Health 2020-02-06 · Fire 2020-02-06
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-16
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
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 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
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 2025-02-14
D · Potential for more than minimal harm
2025-01-16
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 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
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 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-14
D · Potential for more than minimal harm
2023-08-17
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 2023-10-02
D · Potential for more than minimal harm
2023-08-17
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-17
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-10-02
D · Potential for more than minimal harm
2020-02-06
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 2020-03-21
D · Potential for more than minimal harm
2020-02-06
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 2020-03-21
Penalties and ownership
What sits behind the stars
Ownership
Community Place
Operational/Managerial Control · Organization
Hill, Charles
W-2 Managing Employee · Individual
Morris, Charles
Corporate Director · Individual
Morris, Charles
Corporate Officer · Individual
Shelton, Rebecca
Corporate Officer · Individual
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#2
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#3
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4-star overall rating with 3-star inspections with 6 recent health deficiencies
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