Cycle 1
Health 2025-03-20 · Fire 2025-03-20
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Southaven, MS
Diversicare Of Southaven
1-star overall rating with 1-star inspections with $59,175 in total fines with 12 recent health deficiencies
1730 Dorchester Dr, Southaven, MS
(662) 393-0050
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
135
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Diversicare Healthcare
Operator or chain grouping
Approved since
1989-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
44 facilities
Chain averages 3 overall / 3 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
0.64
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,248
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9985
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.25
Baseline 24.50% · Performance 22.45% · Measure score 2.25 · Achievement 0 · Improvement 2.25
Healthcare-associated infections
6.41
Baseline 8.12% · Performance 5.96% · Measure score 6.41 · Achievement 6.27 · Improvement 6.41
Total nurse turnover
7.11
Baseline 37.74% · Performance 34.62% · Measure score 7.11 · Achievement 7.11 · Improvement 1.92
Adjusted total nurse staffing
2.34
Baseline 3.98 hours · Performance 3.74 hours · Measure score 2.34 · Achievement 2.34 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.31% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 176 · Observed rate 13.64% · Lower 95% interval 8.53% |
| Discharge to community | 64.93% |
50.57%
14.4 pts better
|
Better than the National Rate · Eligible stays 135 · Observed rate 52.59% · Lower 95% interval 56.04% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 93.8% |
95.27%
1.5 pts worse
|
Numerator 121 · Denominator 129 |
| Falls with major injury | 0.78% |
0.77%
About the same
|
Numerator 1 · Denominator 129 |
| Discharge self-care score | 35.23% |
53.69%
18.5 pts worse
|
Numerator 31 · Denominator 88 |
| Discharge mobility score | 42.05% |
50.94%
8.9 pts worse
|
Numerator 37 · Denominator 88 |
| Pressure ulcers or injuries, new or worsened | 7.75% |
2.29%
5.5 pts worse
|
Numerator 10 · Denominator 129 · Adjusted rate 5.57% |
| Healthcare-associated infections requiring hospitalization | 5.96% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 5.21% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 32.73% |
8.2%
24.5 pts better
|
Numerator 36 · Denominator 110 |
| Staff flu vaccination coverage | 32.14% |
42%
9.9 pts worse
|
Numerator 36 · Denominator 112 |
| Discharge function score | 42.05% |
56.45%
14.4 pts worse
|
Numerator 37 · Denominator 88 |
| Transfer of health information to provider | 98.31% |
95.95%
2.4 pts better
|
Numerator 58 · Denominator 59 |
| Transfer of health information to patient | 92.86% |
96.28%
3.4 pts worse
|
Numerator 26 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 4.55% |
25.2%
20.6 pts worse
|
Numerator 3 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.4
0.4 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.7 · 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 1.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.8% |
95.7%
0.9 pts worse
|
93.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 94.0% · Q3 92.1% · Q4 97.4% · 4Q avg 94.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.2% |
97.0%
6.8 pts worse
|
95.5%
5.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.2%
2.1 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 0.0% · Q4 0.9% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.2% |
1.6%
1.4 pts better
|
11.4%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
6.1%
1.1 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 2.2% · Q3 12.2% · Q4 4.2% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.3% |
24.4%
9.9 pts worse
|
19.6%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.6% · Q2 32.6% · Q3 35.1% · Q4 36.6% · 4Q avg 34.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
23.4%
17.2 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.7% · Q3 6.2% · Q4 4.6% · 4Q avg 6.2% · 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 0.9% · Q2 0.9% · Q3 0.9% · Q4 0.9% · 4Q avg 0.9% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.6% |
22.8%
4.8 pts worse
|
16.3%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 33.0% · Q4 16.8% · 4Q avg 27.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.3% |
20.6%
2.3 pts better
|
14.9%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 19.8% · Q3 15.1% · Q4 17.2% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
1.5%
0.6 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.5% · Q3 1.2% · Q4 3.6% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
2.5%
0.5 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 0.9% · Q3 0.9% · Q4 1.8% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.2% |
21.4%
6.2 pts better
|
19.8%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 15.1% · Q3 18.1% · Q4 13.6% · 4Q avg 15.2% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
6.9%
0.5 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 8.9% · Q3 8.8% · Q4 6.4% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.6% |
87.9%
2.7 pts better
|
81.7%
8.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.2% · Q2 90.5% · Q3 90.8% · Q4 91.0% · 4Q avg 90.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
15.3%
7.7 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 8.4% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
2.6%
0.9 pts better
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.9% · Q3 1.0% · Q4 1.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.5% |
84.6%
5.9 pts better
|
79.7%
10.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.9% |
27.9%
8 pts better
|
23.9%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 21.8% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-02 · Fire 2023-11-02
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-07-27 · Fire 2022-07-27
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-11-02
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-12-13
F · Potential for more than minimal harm
2022-07-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-07-27
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-09-09
F · Potential for more than minimal harm
2022-07-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-09
Inspection history
Recent health citations
G · Actual harm
2025-03-26
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 2025-04-16
G · Actual harm
2025-03-26
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 2025-04-16
F · Potential for more than minimal harm
2025-03-20
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 2025-04-16
E · Potential for more than minimal harm
2025-03-20
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-16
E · Potential for more than minimal harm
2025-03-20
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 2025-04-16
E · Potential for more than minimal harm
2025-03-20
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 2025-04-16
E · Potential for more than minimal harm
2025-03-20
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 2025-04-16
E · Potential for more than minimal harm
2025-03-20
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 2025-04-16
E · Potential for more than minimal harm
2025-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-20
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 2025-04-16
D · Potential for more than minimal harm
2025-03-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-20
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-04-16
G · Actual harm
2024-05-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-03
J · Immediate jeopardy
2024-04-09
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 2024-04-02
J · Immediate jeopardy
2024-04-09
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 2024-04-02
E · Potential for more than minimal harm
2024-03-20
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 2024-06-03
D · Potential for more than minimal harm
2024-03-20
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 2024-06-03
D · Potential for more than minimal harm
2024-03-20
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 2024-06-03
D · Potential for more than minimal harm
2024-03-20
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 2024-06-03
D · Potential for more than minimal harm
2024-03-20
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 2024-06-03
D · Potential for more than minimal harm
2024-03-20
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-06-03
G · Actual harm
2023-11-02
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 2023-11-27
G · Actual harm
2023-11-02
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-11-27
F · Potential for more than minimal harm
2023-11-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-27
E · Potential for more than minimal harm
2023-11-02
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 2023-11-27
D · Potential for more than minimal harm
2023-11-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-11-02
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 2023-11-27
D · Potential for more than minimal harm
2023-11-02
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 2023-11-27
D · Potential for more than minimal harm
2023-11-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-11-02
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-11-27
E · Potential for more than minimal harm
2022-07-27
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 2022-09-09
E · Potential for more than minimal harm
2022-07-27
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-07-27
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 2022-09-09
D · Potential for more than minimal harm
2022-07-27
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-09-09
D · Potential for more than minimal harm
2022-07-27
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 2022-09-09
D · Potential for more than minimal harm
2022-07-27
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 2022-09-09
D · Potential for more than minimal harm
2022-07-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-09
Penalties and ownership
What sits behind the stars
$6,474
2025-03-20
Fine
Fine · fine $6,474
Fine
$6,474
2025-03-20
Fine
Fine · fine $6,474
Fine
$6,422
2024-03-20
Fine
Fine · fine $6,422
Fine
$6,422
2024-03-20
Fine
Fine · fine $6,422
Fine
$23,491
2024-03-20
Fine
Fine · fine $23,491
Fine
$4,946
2023-11-02
Fine
Fine · fine $4,946
Fine
$4,946
2023-11-02
Fine
Fine · fine $4,946
Fine
$0
2023-11-02
Payment Denial
Payment Denial · denial start 2023-11-28 · 15 days
15 day denial
Ownership
Diversicare Leasing Company Iii LLC
5% Or Greater Direct Ownership Interest · Organization
Advocat Finance, LLC
5% Or Greater Indirect Ownership Interest · Organization
Bodie, Rebecca
Corporate Officer · Individual
Dac Acquisition LLC
5% Or Greater Indirect Ownership Interest · Organization
Dac Newcorp Inc
5% Or Greater Indirect Ownership Interest · Organization
Diversicare Healthcare Services LLC
5% Or Greater Indirect Ownership Interest · Organization
Diversicare Management Services LP.
5% Or Greater Indirect Ownership Interest · Organization
Dms Gp LLC
General Partnership Interest · Organization
Kellman, Franklin
Corporate Director · Individual
Kohn, Brian
Corporate Director · Individual
Nee, Stephen
Corporate Officer · Individual
Ratner, Eran
Operational/Managerial Control · Individual
Ratner, Eran
Corporate Director · Individual
Ratner, Eran
Corporate Officer · Individual
Small, Charles
Operational/Managerial Control · Individual
Weishaar, Matthew
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Desoto Healthcare Center
Southaven, MS
3-star overall rating with 3-star inspections with $9,318 in total fines with 3 recent health deficiencies
#2
Landmark Of Desoto
Horn Lake, MS
2-star overall rating with 2-star inspections with $10,527 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Graceland Rehabilitation And Nursing Care Center
Memphis, TN
1-star overall rating with 1-star inspections with Special Focus status with $342,603 in total fines with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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