Cycle 1
Health 2025-07-31 · Fire 2025-07-31
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cleveland, MS
Delta Rehabilitation And Healthcare Center
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
200 Dr Martin Luther King Jr Drive, Cleveland, MS
(662) 843-5347
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
75
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nexion Health
Operator or chain grouping
Approved since
1996-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
52 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
0.71
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.17
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.61
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
0.76
CMS adjusted RN staffing hours
Adjusted total hours
3.40
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,868
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9865
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0.86
Baseline 7.53% · Performance 7.58% · Measure score 0.86 · Achievement 0.86 · Improvement 0
Total nurse turnover
6.46
Baseline 54.55% · Performance 37.29% · Measure score 6.46 · Achievement 6.46 · Improvement 5.31
Adjusted total nurse staffing
2.13
Baseline 3.71 hours · Performance 3.68 hours · Measure score 2.13 · Achievement 2.13 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.43% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 23.26% · Lower 95% interval 8.73% |
| Discharge to community | 42.13% |
50.57%
8.4 pts worse
|
No Different than the National Rate · Eligible stays 44 · Observed rate 25% · Lower 95% interval 31.8% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 45 · Denominator 45 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 45 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 15.56% |
2.29%
13.3 pts worse
|
Numerator 7 · Denominator 45 · Adjusted rate 8.1% |
| Healthcare-associated infections requiring hospitalization | 7.58% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 11.11% · Lower 95% interval 3.87% |
| Staff COVID-19 vaccination coverage | 1.2% |
8.2%
7 pts worse
|
Numerator 1 · Denominator 83 |
| Staff flu vaccination coverage | 3.49% |
42%
38.5 pts worse
|
Numerator 3 · Denominator 86 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | 20.83% |
25.2%
4.4 pts worse
|
Numerator 5 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 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 | 1.2% |
3.2%
2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.6% · Q4 1.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.5% |
1.6%
1.9 pts worse
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.9% · Q3 4.3% · Q4 4.1% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 11.7% |
6.1%
5.6 pts worse
|
5.4%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 5.4% · Q3 15.5% · Q4 13.6% · 4Q avg 11.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
24.4%
9.1 pts better
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 14.0% · Q3 13.6% · Q4 15.0% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 29.6% |
23.4%
6.2 pts worse
|
16.7%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.6% · Q2 31.2% · Q3 27.7% · Q4 27.5% · 4Q avg 29.6% · 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 | 26.2% |
22.8%
3.4 pts worse
|
16.3%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
20.6%
0.1 pts worse
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 22.7% · Q3 17.8% · Q4 25.5% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.4% |
1.5%
2.9 pts worse
|
1.0%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.9% · Q3 4.1% · Q4 3.4% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.5%
1.3 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 0.0% · Q4 1.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.1% |
21.4%
4.3 pts better
|
19.8%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 18.4% · Q3 15.1% · Q4 11.2% · 4Q avg 17.1% |
| Percentage of long-stay residents with pressure ulcers | 12.9% |
6.9%
6 pts worse
|
5.1%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 13.2% · Q3 16.9% · Q4 11.6% · 4Q avg 12.9% · 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 97.4% · Q2 95.7% · Q3 96.0% · Q4 90.6% · 4Q avg 94.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.6% |
15.3%
8.7 pts better
|
12.0%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.6% · Observed 8.3% · Expected 14.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
2.6%
0.7 pts better
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.7% · Q4 3.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.8% |
84.6%
3.2 pts better
|
79.7%
8.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.1% |
27.9%
7.2 pts worse
|
23.9%
11.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.1% · Observed 44.4% · Expected 30.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
2 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-10-28 · Fire 2022-10-28
5 health deficiencies
Top issue: Resident Rights (3 deficiencies)
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
2025-07-31
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-08-22
F · Potential for more than minimal harm
2023-11-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-08
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-31
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-07-31
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-07-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-07-31
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 2025-09-09
D · Potential for more than minimal harm
2025-07-31
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 2025-09-09
D · Potential for more than minimal harm
2025-07-31
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 2025-09-09
D · Potential for more than minimal harm
2025-07-31
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-02-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-11-15
D · Potential for more than minimal harm
2023-11-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-09-13
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 2023-10-13
D · Potential for more than minimal harm
2023-09-13
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 2023-10-13
D · Potential for more than minimal harm
2023-09-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-13
D · Potential for more than minimal harm
2022-10-28
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 2022-11-22
D · Potential for more than minimal harm
2022-10-28
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-11-22
Penalties and ownership
What sits behind the stars
Ownership
Nexion Health Of Ohi Inc
5% Or Greater Direct Ownership Interest · Organization
Bolt, Bretton
5% Or Greater Indirect Ownership Interest · Individual
Herdrich, William
Corporate Director · Individual
Kirley, Francis
5% Or Greater Indirect Ownership Interest · Individual
Kirley, Francis
Corporate Director · Individual
Kirley, Francis
Corporate Officer · Individual
Lee, Brian
Corporate Director · Individual
Lee, Brian
Corporate Officer · Individual
Matthews, Wanda
W-2 Managing Employee · Individual
Nexion Health Leasing, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Nexion Health, Inc.
Operational/Managerial Control · Organization
Riner, Meera
Corporate Director · Individual
Riner, Meera
Corporate Officer · Individual
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
Cleveland Community Care Center
Cleveland, MS
1-star overall rating with 1-star inspections with $229,213 in total fines with 7 recent health deficiencies
#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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