Lucedale, MS

George Regional Health & Rehab Center

4-star overall rating with 4-star inspections with 5 recent health deficiencies

859 Winter St, Lucedale, MS

(601) 947-9101

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

59

Certified beds

Average residents

42

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2011-10-21

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

0.77

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.84

Licensed practical nurse staffing · state 1.10 · national 0.87

Aide hours / resident day

2.21

Nurse aide staffing · state 2.48 · national 2.35

Total nurse hours

4.81

All reported nurse hours · state 4.21 · national 3.89

Licensed hours

2.60

RN + LPN hours · state 1.73 · national 1.54

Weekend hours

3.66

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.24

Weekend registered nurse coverage · state 0.37 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.97

CMS adjusted RN staffing hours

Adjusted total hours

6.07

CMS adjusted total nurse staffing hours

Case-mix index

1.08

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

37%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

244

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

75.99

Composite VBP score used to determine payment impact.

Payment multiplier

1.0248

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

5.37

Baseline 6.23% · Performance 6.23% · Measure score 5.37 · Achievement 5.37 · Improvement 0

Total nurse turnover

7.42

Baseline 49.06% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 6

Adjusted total nurse staffing

10

Baseline 5.14 hours · Performance 6.27 hours · Measure score 10 · Achievement 10 · Improvement 9

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.01%	10.72% 1.3 pts worse	No Different than the National Rate · Eligible stays 61 · Observed rate 14.75% · Lower 95% interval 8.25%
Discharge to community	52.8%	50.57% 2.2 pts better	No Different than the National Rate · Eligible stays 53 · Observed rate 52.83% · Lower 95% interval 43.25%
Medicare spending per beneficiary	0.68	1.02 0.3 pts better
Drug regimen review with follow-up	95.16%	95.27% 0.1 pts worse	Numerator 59 · Denominator 62
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 62
Discharge self-care score	28.26%	53.69% 25.4 pts worse	Numerator 13 · Denominator 46
Discharge mobility score	23.91%	50.94% 27 pts worse	Numerator 11 · Denominator 46
Pressure ulcers or injuries, new or worsened	1.61%	2.29% 0.7 pts better	Numerator 1 · Denominator 62 · Adjusted rate 1.4%
Healthcare-associated infections requiring hospitalization	6.23%	7.12% 0.9 pts better	No Different than the National Rate · Eligible stays 25 · Observed rate 0% · Lower 95% interval 3.46%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 79
Staff flu vaccination coverage	61.54%	42% 19.5 pts better	Numerator 48 · Denominator 78
Discharge function score	36.96%	56.45% 19.5 pts worse	Numerator 17 · Denominator 46
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 42 · Denominator 42
Resident COVID-19 vaccinations up to date	0%	25.2% 25.2 pts worse	Numerator 0 · Denominator 38

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.8	2.4 0.6 pts better	1.9 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.3 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	4.7	2.9 1.8 pts worse	1.8 2.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 4.7 · Observed 3.8 · Expected 1.4 · Used in QM five-star
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	8.0%	3.2% 4.8 pts worse	3.3% 4.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 11.4% · Q3 8.1% · Q4 2.9% · 4Q avg 8.0% · 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	5.6%	6.1% 0.5 pts better	5.4% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 6.1% · Q3 9.1% · Q4 0.0% · 4Q avg 5.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.4%	24.4% 5 pts better	19.6% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 23.5% · Q3 14.7% · Q4 18.8% · 4Q avg 19.4%
Percentage of long-stay residents who received an antipsychotic medication	35.5%	23.4% 12.1 pts worse	16.7% 18.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 34.5% · Q3 28.6% · Q4 39.3% · 4Q avg 35.5% · 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	18.5%	22.8% 4.3 pts better	16.3% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q4 23.1% · 4Q avg 18.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	17.9%	20.6% 2.7 pts better	14.9% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 25.8% · Q3 16.1% · Q4 20.0% · 4Q avg 17.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	3.8%	1.5% 2.3 pts worse	1.0% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 5.3% · Q4 6.3% · 4Q avg 3.8% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.5%	2.5% 1 pts better	1.7% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	15.5%	21.4% 5.9 pts better	19.8% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 18.4% · Q3 14.2% · Q4 12.1% · 4Q avg 15.5%
Percentage of long-stay residents with pressure ulcers	5.9%	6.9% 1 pts better	5.1% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.8% · Q3 8.8% · Q4 6.1% · 4Q avg 5.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	87.9% 12.1 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	28.1%	15.3% 12.8 pts worse	12.0% 16.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 28.1% · Observed 25.8% · Expected 10.2% · 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 · Q1 2.3% · Q2 4.2% · Q3 2.6% · Q4 2.2% · 4Q avg 2.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	84.6% 15.4 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	33.6%	27.9% 5.7 pts worse	23.9% 9.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 33.6% · Observed 28.8% · Expected 20.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-01 · Fire 2025-05-01

5 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2023-12-20 · Fire 2023-12-20

8 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2021-10-13 · Fire 2021-10-13

4 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2021-10-13

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-09-23

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-05-01

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-05-19

D · Potential for more than minimal harm 2025-05-01

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-05-19

D · Potential for more than minimal harm 2025-05-01

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-05-19

D · Potential for more than minimal harm 2025-05-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-05-19

C · Minimal harm 2025-05-01

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2025-05-19

F · Potential for more than minimal harm 2023-12-20

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 2024-01-12

E · Potential for more than minimal harm 2023-12-20

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2024-01-12