Cycle 1
Health 2025-06-25 · Fire 2025-06-25
11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Byhalia, MS
Great Oaks Rehabilitation And Healthcare Center
1-star overall rating with 2-star inspections with $13,520 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
111 Chase Street, Byhalia, MS
(662) 838-3670
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nexion Health
Operator or chain grouping
Approved since
2005-02-24
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
0.50
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.55
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
4.20
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
2.05
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.47
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.22
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
0.56
CMS adjusted RN staffing hours
Adjusted total hours
4.65
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,817
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.54
Composite VBP score used to determine payment impact.
Payment multiplier
1.0011
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.90
Baseline 25.48% · Performance 20.07% · Measure score 5.90 · Achievement 2.94 · Improvement 5.90
Healthcare-associated infections
6.09
Baseline 13.09% · Performance 7.76% · Measure score 6.09 · Achievement 0 · Improvement 6.09
Total nurse turnover
1.75
Baseline 71.05% · Performance 60.66% · Measure score 1.75 · Achievement 0.74 · Improvement 1.75
Adjusted total nurse staffing
5.28
Baseline 5.19 hours · Performance 4.58 hours · Measure score 5.28 · Achievement 5.28 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.39% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 180 · Observed rate 12.78% · Lower 95% interval 8.23% |
| Discharge to community | 51.5% |
50.57%
0.9 pts better
|
No Different than the National Rate · Eligible stays 175 · Observed rate 42.29% · Lower 95% interval 44.7% |
| Medicare spending per beneficiary | 1.32 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 60% |
95.27%
35.3 pts worse
|
Numerator 60 · Denominator 100 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 100 |
| Discharge self-care score | 43.48% |
53.69%
10.2 pts worse
|
Numerator 20 · Denominator 46 |
| Discharge mobility score | 28.26% |
50.94%
22.7 pts worse
|
Numerator 13 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 1.01% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 99 · Adjusted rate 0.9% |
| Healthcare-associated infections requiring hospitalization | 7.76% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 108 · Observed rate 10.19% · Lower 95% interval 5.26% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 64 |
| Staff flu vaccination coverage | 21.43% |
42%
20.6 pts worse
|
Numerator 15 · Denominator 70 |
| Discharge function score | 43.48% |
56.45%
13 pts worse
|
Numerator 20 · Denominator 46 |
| Transfer of health information to provider | 17.65% |
95.95%
78.3 pts worse
|
Numerator 12 · Denominator 68 |
| Transfer of health information to patient | 77.27% |
96.28%
19 pts worse
|
Numerator 17 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 6.12% |
25.2%
19.1 pts worse
|
Numerator 3 · Denominator 49 |
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 | 97.1% |
97.0%
0.1 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
3.2%
2.4 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · 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 | 4.1% |
6.1%
2 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 8.3% · Q4 3.7% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 47.1% |
24.4%
22.7 pts worse
|
19.6%
27.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.2% · Q2 50.0% · Q3 44.0% · Q4 48.3% · 4Q avg 47.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.9% |
23.4%
10.5 pts better
|
16.7%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 15.0% · 4Q avg 12.9% · 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 | 37.9% |
22.8%
15.1 pts worse
|
16.3%
21.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 37.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.2% |
20.6%
0.6 pts worse
|
14.9%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 33.3% · Q3 4.3% · Q4 18.5% · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
1.5%
0.1 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.4% · Q3 3.1% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
2.5%
0.8 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 3.6% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.2% |
21.4%
0.2 pts better
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 12.7% · Q3 30.3% · Q4 16.2% · 4Q avg 21.2% |
| Percentage of long-stay residents with pressure ulcers | 10.3% |
6.9%
3.4 pts worse
|
5.1%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 9.5% · Q3 7.0% · Q4 7.9% · 4Q avg 10.3% · 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 | 15.4% |
15.3%
0.1 pts worse
|
12.0%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.4% · Observed 15.1% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.1% |
2.6%
1.5 pts worse
|
1.6%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.8% · Q3 5.1% · Q4 4.1% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.7% |
84.6%
14.1 pts better
|
79.7%
19 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.0% |
27.9%
10.1 pts worse
|
23.9%
14.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 38.0% · Observed 35.5% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-04 · Fire 2024-01-04
10 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 2022-11-16 · Fire 2022-11-16
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-07-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-06
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 2025-12-26
D · Potential for more than minimal harm
2025-11-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-11-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-11-06
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 2025-12-26
D · Potential for more than minimal harm
2025-06-25
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-25
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 2025-07-21
D · Potential for more than minimal harm
2025-06-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-25
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 2025-07-21
D · Potential for more than minimal harm
2025-06-25
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 2025-07-21
G · Actual harm
2025-05-22
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 2025-06-11
E · Potential for more than minimal harm
2024-10-01
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 2024-11-07
D · Potential for more than minimal harm
2024-10-01
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-05-15
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 2024-06-14
E · Potential for more than minimal harm
2024-01-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-02
D · Potential for more than minimal harm
2024-01-04
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 2024-02-02
D · Potential for more than minimal harm
2024-01-04
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 2024-02-02
D · Potential for more than minimal harm
2024-01-04
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 2024-02-02
D · Potential for more than minimal harm
2024-01-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-02
D · Potential for more than minimal harm
2024-01-04
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 2024-02-02
D · Potential for more than minimal harm
2024-01-04
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 2024-02-02
D · Potential for more than minimal harm
2022-11-16
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 2022-12-29
D · Potential for more than minimal harm
2022-11-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-29
D · Potential for more than minimal harm
2022-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-29
Penalties and ownership
What sits behind the stars
$13,520
2025-05-22
Fine
Fine · fine $13,520
Fine
Ownership
Nexion Health Of Ohi Inc
5% Or Greater Direct Ownership Interest · Organization
Bolt, Bretton
5% Or Greater Indirect Ownership Interest · Individual
Kirley, Francis
5% Or Greater Indirect Ownership Interest · Individual
Kirley, Francis
Operational/Managerial Control · Individual
Kirley, Francis
Corporate Director · Individual
Kirley, Francis
Corporate Officer · Individual
Lee, Brian
Corporate Director · Individual
Lee, Brian
Corporate Officer · Individual
Nexion Health Leasing, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Nexion Health, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Oswald, John
Corporate Director · Individual
Pierce, Daniel
Corporate Officer · Individual
Reid, John
Corporate Director · Individual
Riner, Meera
Corporate Director · Individual
Riner, Meera
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Collierville Nursing And Rehabilitation, Llc
Collierville, TN
1-star overall rating with 2-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
The Suites At Jordan River
Collierville, TN
2-star overall rating with 2-star inspections with $27,169 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Kirby Pines Manor
Memphis, TN
5-star overall rating with 5-star inspections with 2 recent health deficiencies
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