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
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
0.75
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.54
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
3.03
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
5.31
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
2.28
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.68
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
5.93
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,427
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.98% · Performance 21.96% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.06% · Performance 8.80% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 62.16% · Performance 98.68% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
6.72
Baseline 4.50 hours · Performance 4.99 hours · Measure score 6.72 · Achievement 6.72 · Improvement 3.31
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.41% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 93 · Observed rate 5.38% · Lower 95% interval 5.96% |
| Discharge to community | 57.11% |
50.57%
6.5 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 55.42% · Lower 95% interval 45.67% |
| Medicare spending per beneficiary | 1.31 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 98% |
95.27%
2.7 pts better
|
Numerator 49 · Denominator 50 |
| Falls with major injury | 2% |
0.77%
1.2 pts worse
|
Numerator 1 · Denominator 50 |
| Discharge self-care score | 55.88% |
53.69%
2.2 pts better
|
Numerator 19 · Denominator 34 |
| Discharge mobility score | 35.29% |
50.94%
15.6 pts worse
|
Numerator 12 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 4% |
2.29%
1.7 pts worse
|
Numerator 2 · Denominator 50 · Adjusted rate 3.31% |
| Healthcare-associated infections requiring hospitalization | 8.8% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 11.94% · Lower 95% interval 5.4% |
| Staff COVID-19 vaccination coverage | 15.56% |
8.2%
7.4 pts better
|
Numerator 14 · Denominator 90 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 47.06% |
56.45%
9.4 pts worse
|
Numerator 16 · Denominator 34 |
| 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 | 78.26% |
96.28%
18 pts worse
|
Numerator 18 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 45% |
25.2%
19.8 pts better
|
Numerator 9 · Denominator 20 |
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 · Adjusted 3.1 · Observed 2.2 · Expected 1.4 · Used in QM five-star |
| 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 · Adjusted 1.3 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| 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 · Q1 98.2% · Q2 100.0% · Q3 100.0% · Q4 89.8% · 4Q avg 97.2% |
| 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 | 1.9% |
3.2%
1.3 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · 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 | 1.1% |
6.1%
5 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| 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 · Q1 20.4% · Q2 14.6% · Q3 15.9% · Q4 21.4% · 4Q avg 18.0% |
| 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 · Q1 28.9% · Q2 22.5% · Q3 21.4% · Q4 21.6% · 4Q avg 23.6% · Used in QM five-star |
| 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 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.9% |
| 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 · 4Q avg 22.7% · Used in QM five-star |
| 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 · Q1 16.7% · Q2 18.2% · Q3 8.6% · Q4 38.2% · 4Q avg 20.5% · Used in QM five-star |
| 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 · Q1 1.9% · Q2 1.2% · Q3 0.0% · Q4 1.3% · 4Q avg 1.1% · Used in QM five-star |
| 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 · Q1 1.9% · Q2 3.6% · Q3 1.9% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| 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 · Q1 19.0% · Q2 18.4% · Q3 38.9% · Q4 28.1% · 4Q avg 26.0% |
| 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 · Q1 13.7% · Q2 10.2% · Q3 5.7% · Q4 12.0% · 4Q avg 10.4% · Used in QM five-star |
| 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 · Q1 95.0% · Q4 100.0% · 4Q avg 98.7% |
| 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 · Adjusted 8.3% · Observed 8.3% · Expected 11.2% · Used in QM five-star |
| 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 · 4Q avg 2.2% · Used in QM five-star |
| 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 · Adjusted 15.6% · Observed 13.9% · Expected 21.2% · Used in QM five-star |
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
Wisteria Gardens
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4-star overall rating with 3-star inspections with 6 recent health deficiencies
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