7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Crystal Springs, MS
2-star overall rating with 3-star inspections with 7 recent health deficiencies
806 West Georgetown Street, Crystal Springs, MS
(601) 892-1880
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
60
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Beebe Family
Operator or chain grouping
Approved since
2002-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
48 facilities
Chain averages 3 overall / 3 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
RN hours / resident day
0.46
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
4.00
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.48
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
4.47
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Program rank
8,891
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9838
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Performance 24.54% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Baseline 5.67% · Performance 9.16% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.35
Baseline 52.63% · Performance 41.82% · Measure score 5.35 · Achievement 5.35 · Improvement 3.39
Adjusted total nurse staffing
4.80
Baseline 3.99 hours · Performance 4.44 hours · Measure score 4.80 · Achievement 4.80 · Improvement 2.03
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.75% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 13.56% · Lower 95% interval 7.54% |
| Discharge to community | 41.72% |
50.57%
8.9 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 35.14% · Lower 95% interval 28.81% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 51 · Denominator 51 |
| Falls with major injury | 1.96% |
0.77%
1.2 pts worse
|
Numerator 1 · Denominator 51 |
| Discharge self-care score | 60.71% |
53.69%
7 pts better
|
Numerator 17 · Denominator 28 |
| Discharge mobility score | 39.29% |
50.94%
11.6 pts worse
|
Numerator 11 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 7.84% |
2.29%
5.5 pts worse
|
Numerator 4 · Denominator 51 · Adjusted rate 6.25% |
| Healthcare-associated infections requiring hospitalization | 9.16% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 13.73% · Lower 95% interval 5.47% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 74 |
| Staff flu vaccination coverage | 63.16% |
42%
21.2 pts better
|
Numerator 60 · Denominator 95 |
| Discharge function score | 53.57% |
56.45%
2.9 pts worse
|
Numerator 15 · Denominator 28 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 42.86% |
25.2%
17.7 pts better
|
Numerator 9 · Denominator 21 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.5 |
2.4
1.1 pts worse
|
1.9
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.6 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.6 |
2.9
0.7 pts worse
|
1.8
1.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 3.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
95.7%
3.3 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
97.0%
1.1 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.2%
1.9 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 6.1% · Q3 3.9% · Q4 0.0% · 4Q avg 5.1% · 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 | 0.6% |
6.1%
5.5 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
24.4%
8.4 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 17.0% · Q3 20.4% · Q4 14.0% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.8% |
23.4%
8.4 pts worse
|
16.7%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 27.0% · Q3 36.8% · Q4 29.7% · 4Q avg 31.8% · 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 | 30.3% |
22.8%
7.5 pts worse
|
16.3%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.4% |
20.6%
6.8 pts worse
|
14.9%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.3% · Q2 22.2% · Q3 28.9% · Q4 15.4% · 4Q avg 27.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.5%
1.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.5%
0.9 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.3% · Q3 2.1% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
21.4%
1.8 pts better
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 32.9% · Q3 13.9% · Q4 20.2% · 4Q avg 19.6% |
| Percentage of long-stay residents with pressure ulcers | 13.4% |
6.9%
6.5 pts worse
|
5.1%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 13.7% · Q3 10.5% · Q4 13.6% · 4Q avg 13.4% · 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 · Q2 95.0% · Q4 95.5% · 4Q avg 94.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
15.3%
3.5 pts better
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 11.6% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
2.6%
0.3 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.0% |
84.6%
5.4 pts better
|
79.7%
10.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.5% |
27.9%
4.6 pts worse
|
23.9%
8.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.5% · Observed 25.6% · Expected 18.8% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-11-26
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-11-26
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 2025-06-04
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-06-04
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-04
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-06-04
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-04
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-01
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-12-01
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-01
Health
Assess the resident when there is a significant change in condition
Corrected 2023-12-01
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 2023-12-01
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-12-29
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-12-29
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-12-29
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-12-29
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-12-29
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-12-29
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-12-29
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-12-29
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-29
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
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