Cycle 1
Health 2024-07-18 · Fire 2024-07-18
8 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Grenada, MS
Grenada Rehabilitation And Healthcare Center
1-star overall rating with 1-star inspections with abuse icon flag with $14,800 in total fines with 8 recent health deficiencies
1966 Hill Drive, Grenada, MS
(662) 226-2442
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nexion Health
Operator or chain grouping
Approved since
1992-09-17
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
0.49
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.63
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.82
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,540
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9925
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.60
Baseline 18.17% · Performance 20.23% · Measure score 2.60 · Achievement 2.60 · Improvement 0
Healthcare-associated infections
2.16
Baseline 8.12% · Performance 7.29% · Measure score 2.16 · Achievement 1.84 · Improvement 2.16
Total nurse turnover
7.09
Performance 34.69% · Measure score 7.09 · Achievement 7.09 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.96
Baseline 3.95 hours · Performance 4.20 hours · Measure score 3.96 · Achievement 3.96 · Improvement 0.91
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.5% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 11.84% · Lower 95% interval 7.92% |
| Discharge to community | 56.49% |
50.57%
5.9 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 44.78% · Lower 95% interval 46.15% |
| Medicare spending per beneficiary | 1.25 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 70 · Denominator 70 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 70 |
| Discharge self-care score | 32.43% |
53.69%
21.3 pts worse
|
Numerator 12 · Denominator 37 |
| Discharge mobility score | 27.03% |
50.94%
23.9 pts worse
|
Numerator 10 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 5.71% |
2.29%
3.4 pts worse
|
Numerator 4 · Denominator 70 · Adjusted rate 4.41% |
| Healthcare-associated infections requiring hospitalization | 7.29% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 8.33% · Lower 95% interval 4.18% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 132 |
| Staff flu vaccination coverage | 1.63% |
42%
40.4 pts worse
|
Numerator 2 · Denominator 123 |
| Discharge function score | 29.73% |
56.45%
26.7 pts worse
|
Numerator 11 · Denominator 37 |
| Transfer of health information to provider | 97.83% |
95.95%
1.9 pts better
|
Numerator 45 · Denominator 46 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
2.4
1.7 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 1.0 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.9
0.4 pts better
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 3.1 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
95.7%
4 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
97.0%
1.8 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| 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 0.0% · Q3 1.1% · Q4 3.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
1.6%
1.2 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 10.2% |
6.1%
4.1 pts worse
|
5.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 10.4% · Q3 12.9% · Q4 7.6% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.4% |
24.4%
8 pts worse
|
19.6%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.6% · Q2 29.5% · Q3 31.8% · Q4 32.9% · 4Q avg 32.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.9% |
23.4%
3.5 pts better
|
16.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 22.6% · Q3 19.7% · Q4 19.3% · 4Q avg 19.9% · 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 | 35.1% |
22.8%
12.3 pts worse
|
16.3%
18.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 33.0% · 4Q avg 35.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.7% |
20.6%
7.1 pts worse
|
14.9%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 35.6% · Q3 26.8% · Q4 21.9% · 4Q avg 27.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.5%
0.9 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 1.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
2.5%
2.2 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
21.4%
3.5 pts worse
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 23.2% · Q3 28.8% · Q4 33.2% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
6.9%
1.6 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 6.8% · Q3 7.0% · Q4 6.9% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
87.9%
9.7 pts better
|
81.7%
15.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 98.8% · Q3 98.8% · Q4 100.0% · 4Q avg 97.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.6% |
15.3%
4.3 pts worse
|
12.0%
7.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 22.0% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
2.6%
0.1 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 4.5% · Q4 2.1% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.8% |
84.6%
14.2 pts better
|
79.7%
19.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.7% |
27.9%
14.2 pts better
|
23.9%
10.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 14.0% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-15 · Fire 2023-05-15
15 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-02-20 · Fire 2020-02-20
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2020-02-20
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2020-03-29
Inspection history
Recent health citations
G · Actual harm
2025-10-29
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-19
F · Potential for more than minimal harm
2025-10-29
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 2025-11-19
D · Potential for more than minimal harm
2025-08-13
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-08
F · Potential for more than minimal harm
2024-07-18
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 2024-08-22
D · Potential for more than minimal harm
2024-07-18
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 2024-08-22
D · Potential for more than minimal harm
2024-07-18
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-08-22
D · Potential for more than minimal harm
2024-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-22
B · Minimal harm
2024-07-18
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-08-22
B · Minimal harm
2024-07-18
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-08-22
F · Potential for more than minimal harm
2023-05-15
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 2023-06-15
E · Potential for more than minimal harm
2023-05-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-15
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 2023-06-15
D · Potential for more than minimal harm
2023-05-15
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 2023-06-15
D · Potential for more than minimal harm
2023-05-15
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-15
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-15
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 2023-06-15
D · Potential for more than minimal harm
2023-05-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-15
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-15
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 2023-06-15
D · Potential for more than minimal harm
2023-05-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-15
J · Immediate jeopardy
2023-03-03
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 2023-03-31
J · Immediate jeopardy
2023-03-03
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 2023-03-31
F · Potential for more than minimal harm
2020-02-20
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 2020-03-29
E · Potential for more than minimal harm
2020-02-20
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 2020-03-29
D · Potential for more than minimal harm
2020-02-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-03-29
D · Potential for more than minimal harm
2020-02-20
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 2020-03-29
D · Potential for more than minimal harm
2020-02-20
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 2020-03-29
Penalties and ownership
What sits behind the stars
$14,800
2025-10-29
Fine
Fine · fine $14,800
Fine
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, Jonathan
Operational/Managerial Control · Individual
Matthews, Jonathan
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
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