Holly Springs, MS

Holly Springs Rehabilitation And Healthcare Center

1-star overall rating with 2-star inspections with $8,278 in total fines with 10 recent health deficiencies

1315 Highway 4 East, Holly Springs, MS

(662) 252-1141

Compare this facility

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

120

Certified beds

Average residents

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

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

0.45

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.15

Licensed practical nurse staffing · state 1.10 · national 0.87

Aide hours / resident day

2.35

Nurse aide staffing · state 2.48 · national 2.35

Total nurse hours

3.96

All reported nurse hours · state 4.21 · national 3.89

Licensed hours

1.61

RN + LPN hours · state 1.73 · national 1.54

Weekend hours

3.39

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.21

Weekend registered nurse coverage · state 0.37 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.55

CMS adjusted RN staffing hours

Adjusted total hours

4.82

CMS adjusted total nurse staffing hours

Case-mix index

1.12

Higher values indicate more complex resident acuity

RN turnover

13%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

50%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,027

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

Performance score

30.99

Composite VBP score used to determine payment impact.

Payment multiplier

0.9863

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 20.87% · Performance 21.59% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

3.44

Baseline 9.36% · Performance 7.64% · Measure score 3.44 · Achievement 0.64 · Improvement 3.44

Total nurse turnover

3.46

Baseline 69.44% · Performance 51.81% · Measure score 3.46 · Achievement 2.90 · Improvement 3.46

Adjusted total nurse staffing

5.50

Baseline 4.04 hours · Performance 4.64 hours · Measure score 5.50 · Achievement 5.50 · Improvement 2.98

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.19%	10.72% 0.5 pts worse	No Different than the National Rate · Eligible stays 67 · Observed rate 13.43% · Lower 95% interval 7.24%
Discharge to community	54.08%	50.57% 3.5 pts better	No Different than the National Rate · Eligible stays 63 · Observed rate 42.86% · Lower 95% interval 41.29%
Medicare spending per beneficiary	1.02	1.02 About the same
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 36 · Denominator 36
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 36
Discharge self-care score	36%	53.69% 17.7 pts worse	Numerator 9 · Denominator 25
Discharge mobility score	28%	50.94% 22.9 pts worse	Numerator 7 · Denominator 25
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 36 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.64%	7.12% 0.5 pts worse	No Different than the National Rate · Eligible stays 28 · Observed rate 10.71% · Lower 95% interval 3.8%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 96
Staff flu vaccination coverage	20%	42% 22 pts worse	Numerator 22 · Denominator 110
Discharge function score	44%	56.45% 12.5 pts worse	Numerator 11 · Denominator 25
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	5%	25.2% 20.2 pts worse	Numerator 1 · Denominator 20

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	3.9%	3.2% 0.7 pts worse	3.3% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 5.3% · Q3 5.1% · Q4 2.5% · 4Q avg 3.9% · 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	0.4%	6.1% 5.7 pts better	5.4% 5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	25.1%	24.4% 0.7 pts worse	19.6% 5.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 25.0% · Q3 24.6% · Q4 24.7% · 4Q avg 25.1%
Percentage of long-stay residents who received an antipsychotic medication	32.7%	23.4% 9.3 pts worse	16.7% 16 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 36.2% · Q2 33.3% · Q3 32.7% · Q4 29.3% · 4Q avg 32.7% · 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	34.7%	22.8% 11.9 pts worse	16.3% 18.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 44.3% · Q2 22.9% · Q3 32.0% · Q4 39.0% · 4Q avg 34.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	27.2%	20.6% 6.6 pts worse	14.9% 12.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 25.8% · Q3 25.0% · Q4 26.9% · 4Q avg 27.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.4%	1.5% 0.1 pts better	1.0% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.2% · Q3 2.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	2.5% 2.5 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	26.1%	21.4% 4.7 pts worse	19.8% 6.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 24.3% · Q3 28.6% · Q4 27.3% · 4Q avg 26.1%
Percentage of long-stay residents with pressure ulcers	4.9%	6.9% 2 pts better	5.1% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 5.2% · Q3 4.6% · Q4 5.4% · 4Q avg 4.9% · 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	16.1%	15.3% 0.8 pts worse	12.0% 4.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 17.5% · Expected 12.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.4%	2.6% 0.2 pts better	1.6% 0.8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.0% · Q3 3.6% · Q4 0.0% · 4Q avg 2.4% · 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	34.6%	27.9% 6.7 pts worse	23.9% 10.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 34.6% · Observed 35.0% · Expected 24.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-19 · Fire 2025-06-19

10 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-01-04 · Fire 2024-01-04

14 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2022-11-03 · Fire 2022-11-03

1 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2022-11-03

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-12-05

Inspection history

Recent health citations

G · Actual harm 2025-11-24

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 2025-12-19

E · Potential for more than minimal harm 2025-11-24

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-12-19

F · Potential for more than minimal harm 2025-06-19

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 2025-07-18

E · Potential for more than minimal harm 2025-06-19

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 2025-07-18

E · Potential for more than minimal harm 2025-06-19

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 2025-07-18

E · Potential for more than minimal harm 2025-06-19

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-19

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 2025-07-18

D · Potential for more than minimal harm 2025-06-19

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-07-18

D · Potential for more than minimal harm 2025-06-19

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 2025-07-18

D · Potential for more than minimal harm 2025-06-19

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-18

G · Actual harm 2025-01-27

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 2025-02-05

G · Actual harm 2025-01-27

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 2025-02-05

D · Potential for more than minimal harm 2024-09-09

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 2024-10-17

D · Potential for more than minimal harm 2024-09-09

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 2024-10-17

D · Potential for more than minimal harm 2024-06-19

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2024-05-14

E · Potential for more than minimal harm 2024-01-04